This was originally reported by a different user through the Project Cypress Google group, but we found some additional cases where the randomly generated area codes generates  not in use, invalid, and in-use Canadian area codes. 

Example of invalid - 199. Area codes in North America should not start with 0 or 1.

Example of not in use- 459, 674, 846.

Canadian area codes - 579.

Dave, you already mentioned that this is due to randomly generated area codes. I'm not a ruby expert, but it looks like the 'telephone_number' validation gem doesn't handle area codes not in use even though they should have a +1 country code since it falls under the North American Number Plan.

Additionally, we did find a validation error with an in-use Canadian area code, 579. There may be some specific invocation of TelephoneNumber.parse with the :us country code that may be causing this failure from cypress/app/helpers/qrda_helper.rb

telecoms[:phone_list] << TelephoneNumber.parse(uri, :us).e164_number 

If the fix with Cypress 7.1.0 will provision new patients with in-use area codes, I'd recommend filtering it further to US-only area codes.