claims-summarizer · ~/eval-lab

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claims summarizer·eval lab

Prompt-strategy comparison on 20 hand-labeled MA denial scenarios

Three variants scored against the same eval set. Composite is 0.3·category + 0.3·appealability + 0.2·action + 0.2·artifact. Refused→appeal requires both the model’s refusal and a judge action ≥ 0.7 — the “right for the right reason” gate.

Variant	Composite	Category	Appealable	Refused→Appeal	Action	Artifact	Latency	Cache	Run
Zero-shotzero-shot	—	—	—	—	—	—	—	—
Few-shotfew-shot	—	—	—	—	—	—	—	—
Structured-firststructured-extraction-first	—	—	—	—	—	—	—	—

scenarios20 hand-labeled · click to inspect

Medical Necessity — aquatic therapy denied as not medically necessary

Medical Necessityappealable

Medical Necessity — Lumbar MRI denied; conservative care timeline insufficient

Medical Necessityappealable

Medical Necessity — Cardiac rehab extension beyond standard 36 sessions deniedborderline

Medical Necessityappealable

Prior Auth Not Obtained — Outpatient shoulder arthroscopy

Prior Auth Not Obtainedappealable

Prior Auth Not Obtained — IV iron infusionborderline

Prior Auth Not Obtainedappealable

Prior Auth Not Obtained — Emergency surgery during inpatient admission

Prior Auth Not Obtainedappealable

Out-of-Network — ED visit at non-network facility while traveling

Out-of-Networkappealable

Out-of-Network — Elective specialty visit, no network provider unavailableborderline

Out-of-Networkappealable

Step Therapy — Biologic for rheumatoid arthritis denied; methotrexate trial required

Step Therapy / Part D Formularyappealable

Step Therapy — GLP-1 weight-loss indication denied; tier-1 metformin requiredborderline

Step Therapy / Part D Formularyappealable

SNF — Extended post-stroke rehab denied; plan asserts plateau

SNF Skilled-vs-Custodialappealable

SNF — Admission denied; three-day inpatient rule not metborderline

SNF Skilled-vs-Custodialappealable

DME — CPAP rental terminated for documented non-compliance

DME Coverageappealable

DME — Power mobility scooter denied; manual wheelchair preferred

DME Coverageappealable

Duplicate Claim — Provider resubmitted identical paid claim

Duplicate Claimno-appeal

Duplicate Claim — Looks like duplicate but corrected billing pendingborderline

Duplicate Claimno-appeal

Duplicate Claim — Service already bundled into prior procedure code

Duplicate Claimno-appeal

COB — Working-aged member; employer plan primary

COB Second-Payerno-appeal

COB — VA-authorized care for service-connected condition

COB Second-Payerno-appeal

COB — Workers' Compensation pending for occupational injuryborderline

COB Second-Payerno-appeal

$ eval-lab run --variants all --set hand-labeled-20 [idle]

Claims Summarizer — MA denial triage cockpit