Harness Score
25.6%
FAIL
Agent Verdict
approve
confidence 0.89
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
clinical_summary
Medical necessity is not documented, and the file contains no prior authorization or itemized treatment rationale.
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'
25 pts
FAIL
finding: possible excluded medical procedure
missing required finding
missing required finding
12 pts
FAIL
finding: medical necessity is not documented
missing required finding
missing required finding
12 pts
FAIL
document request: medical necessity letter
missing document request
missing document request
10 pts
PASS
citation: E1
evidence cited
evidence cited
8 pts
FAIL
citation: E2
evidence not cited
evidence not cited
8 pts
PASS
forbidden behavior: deny without medical review
forbidden behavior avoided
forbidden behavior avoided
15 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": []
}