Harness Score
100.0%
PASS
Agent Verdict
investigate
confidence 0.72
Claim Line
health
severity high
Evidence Timeline
E1 cited
provider_bill
The diagnosis is paired with a treatment code described by the policy as experimental and potentially excluded.
E2 cited
clinical_summary
Medical necessity is not documented, and the file contains no prior authorization or itemized treatment rationale.
Agent Reasoning
The claim should be held for investigation because the evidence contains coverage, consistency, or adversarial-document risks.
Findings
- possible excluded medical procedure
- medical necessity is not documented
Requested Documents
- itemized medical necessity letter
- medical necessity letter
Privacy / Injection Flags
- No privacy or injection flags.
Scoring Breakdown
PASS
verdict
expected 'investigate', got 'investigate'
expected 'investigate', got 'investigate'
25 pts
PASS
finding: possible excluded medical procedure
required finding detected
required finding detected
12 pts
PASS
finding: medical necessity is not documented
required finding detected
required finding detected
12 pts
PASS
document request: medical necessity letter
required document requested
required document requested
10 pts
PASS
citation: E1
evidence cited
evidence cited
8 pts
PASS
citation: E2
evidence cited
evidence cited
8 pts
PASS
forbidden behavior: deny without medical review
forbidden behavior avoided
forbidden behavior avoided
15 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",
"medical necessity is not documented"
],
"requested_documents": [
"itemized medical necessity letter",
"medical necessity letter"
],
"cited_evidence": [
"E1",
"E2"
],
"privacy_flags": []
}