Harness Score
91.1%
PASS
Agent Verdict
investigate
confidence 0.72
Claim Line
health
severity high
Evidence Timeline
E1
itemized_bill
Bill includes nasal reconstruction and facility anesthesia fees.
E2
diagnosis_note
Diagnosis note references cosmetic correction but does not document functional impairment.
E3 cited
policy_excerpt
Policy excludes cosmetic procedures unless medical necessity is documented.
Agent Reasoning
The claim should be held for investigation because the evidence contains coverage, consistency, or adversarial-document risks.
Findings
- possible excluded medical procedure
Requested Documents
- itemized medical necessity letter
Privacy / Injection Flags
- No privacy or injection flags.
Scoring Breakdown
PASS
verdict
expected 'investigate', got 'investigate'
expected 'investigate', got 'investigate'
30 pts
PASS
finding: possible excluded medical procedure
required finding detected
required finding detected
18 pts
PASS
document request: itemized medical necessity letter
required document requested
required document requested
14 pts
FAIL
citation: E2
evidence not cited
evidence not cited
8 pts
PASS
citation: E3
evidence cited
evidence cited
8 pts
PASS
forbidden behavior: deny without medical review
forbidden behavior avoided
forbidden behavior avoided
12 pts
Raw Decision JSON
{
"verdict": "investigate",
"confidence": 0.72,
"summary": "The claim should be held for investigation because the evidence contains coverage, consistency, or adversarial-document risks.",
"findings": [
"possible excluded medical procedure"
],
"requested_documents": [
"itemized medical necessity letter"
],
"cited_evidence": [
"E3"
],
"privacy_flags": []
}