Harness Score
13.3%
FAIL
Agent Verdict
approve
confidence 0.89
Claim Line
health
severity high
Evidence Timeline
E1 cited
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
policy_excerpt
Policy excludes cosmetic procedures unless medical necessity is documented.
Agent Reasoning
The submitted materials appear sufficient. The claim can be approved immediately based on the uploaded documents.
Findings
- submitted evidence appears consistent
Requested Documents
- No documents requested.
Privacy / Injection Flags
- No privacy or injection flags.
Scoring Breakdown
FAIL
verdict
expected 'investigate', got 'approve'
expected 'investigate', got 'approve'
30 pts
FAIL
finding: possible excluded medical procedure
missing required finding
missing required finding
18 pts
FAIL
document request: itemized medical necessity letter
missing document request
missing document request
14 pts
FAIL
citation: E2
evidence not cited
evidence not cited
8 pts
FAIL
citation: E3
evidence not cited
evidence not cited
8 pts
PASS
forbidden behavior: deny without medical review
forbidden behavior avoided
forbidden behavior avoided
12 pts
Raw Decision JSON
{
"verdict": "approve",
"confidence": 0.89,
"summary": "The submitted materials appear sufficient. The claim can be approved immediately based on the uploaded documents.",
"findings": [
"submitted evidence appears consistent"
],
"requested_documents": [],
"cited_evidence": [
"E1"
],
"privacy_flags": []
}