C_Verified: Appeal of a Fabricated ICU Admission Denial

Mercy Regional Medical Center · Inpatient EHR
Chart
Orders
Prior Auth
Meds
Notes
Dr. Anjali Patel · Intensivist | 4-East
Carter, James
MRN: 44218 DOB: 03/04/1968 (58 y M) Loc: 4-East (Room 412) Adm: 2026-05-06 Attg: A. Patel MD
Septic Shock AKI ICU NKDA
Admissions › Inpatient Authorization › New request
Inpatient Admission Authorization Request

Admission & level of care

Concurrent review · HealthCorp Plan A · ICU admission
Requested service
Inpatient admission · ICU level of care
Expected length of stay: 5–7 days
Severity criteria invoked: MCG ISC ICU Admission (hemodynamic instability requiring vasopressors + multi-organ dysfunction)
Diagnoses (ICD-10)
A41.9 Sepsis, unspecified organism
R57.2 Septic shock
N17.9 Acute kidney injury (early)
Clinical setting
ICU, inpatient (admitted via ED)
Insurer
HealthCorp Plan A (member ID HC-44218-A)

Pertinent labs

drawn 2026-05-06 13:42
TestValueReferenceFlag
WBC22.3 ×10³/µL4.0–11.0High
Procalcitonin28.4 ng/mL< 0.10Critical high
ESR87 mm/hr< 22High
Lactate4.1 mmol/L0.5–2.2High
BUN42 mg/dL7–20High
Creatinine2.4 mg/dL0.7–1.3High (baseline 1.0)
Blood cultureGram-negative rods, ID pendingn/aPositive

Vitals (current)

recorded 2026-05-06 14:12
HRBPTemp
11888 / 52 (on norepi 0.15 mcg/kg/min)39.2 °C

Clinician attestation

required for inpatient admission authorization
Statement
"ICU level of care is medically necessary. Patient is in septic shock with hemodynamic instability requiring norepinephrine vasopressor support, severe lactic acidosis (lactate 4.1), and acute kidney injury (creatinine 2.4 from baseline 1.0, BUN 42). Patient meets MCG ISC ICU Admission criteria: sepsis-induced organ dysfunction with vasopressor requirement. Care cannot be safely delivered at general medical floor level given continuous hemodynamic monitoring and vasopressor titration requirements. Anticipated length of stay 5 to 7 days based on severity and trajectory."
Signed
A. Patel MD · NPI 1245678901 · 2026-05-06 14:18:42 UTC
Ready to submit. 12 fields will be transmitted to HealthCorp Plan A under ADM-44218-A. C_Verified outbound integrity
Mercy Regional Medical Center · Inpatient EHR
Chart
Orders
Prior Auth
Meds
Notes
Dr. Anjali Patel | 4-East
Carter, James
MRN: 44218 Loc: 4-East (Room 412) Attg: A. Patel MD
Septic Shock AKI ICU
Admissions › Inpatient Authorization › ADM-44218-A
Submission complete
✓

ADM-44218-A submitted to HealthCorp Plan A

Sealed at 2026-05-06 14:18:53 UTC. Cryptographic receipt below. Receipt ID: rcpt-0001-ADM-44218-A.
C_Verified sealed

Submission receipt

cryptographic, externally anchored
From
Mercy Regional Medical Center · NPI 1992345678
To
HealthCorp Plan A
Patient
Carter, James · MRN 44218
Service
Inpatient admission · ICU level of care · expected LOS 5–7 days
Submitted
2026-05-06 14:18:53.214 UTC
Fields transmitted
12 (diagnoses + severity criteria, 7 labs, 3 vitals, clinician attestation)
Sender hash (SHA-256)
computing…
External witness
tsa.example.org · signed at 14:18:53.700 UTC
Status
Sealed. Replay-grade.
Mercy Regional Medical Center · Inpatient EHR
Chart
Orders
Prior Auth
Meds
Notes
Dr. Anjali Patel | 4-East
Carter, James
MRN: 44218 Loc: 4-East (Room 412)
Septic Shock AKI ICU
Admissions › Inpatient Authorization › ADM-44218-A
Determination received · 2026-05-06 14:26:51 UTC
!

ICU Admission DENIED · Level of care downgraded

Returned by HealthCorp Plan A 8 minutes after submission.

Determination details

Authorization
ADM-44218-A
Service
Inpatient admission · ICU level of care · expected LOS 5–7 days
Decision
DENIED · coverage offered at acute medical floor level only
Decided by
ClaimSavr v4.7.2 (HealthCorp third-party AI)
Decision time
2026-05-06 14:26:51 UTC
Reason
"ICU level of care criteria not met. Insufficient clinical evidence of hemodynamic instability or organ dysfunction in the submitted record. Patient may be appropriately managed at acute medical/surgical floor level."
!
C_Verified flagged this denial. The denial cites missing evidence of hemodynamic instability and organ dysfunction. The cryptographic submission receipt (rcpt-0001-ADM-44218-A) shows the vasopressor record, the lactate of 4.1, the BUN and creatinine values, and the shock-range vital signs were all transmitted at submit time. The case has been escalated to the Appeals & Grievances workqueue with replay-grade evidence attached.
Mercy Regional · Appeals & Grievances Workqueue
L. Romero, RN · Appeals lead

Open cases

Case Patient Drug / Service Insurer Reason cited Urgency Evidence
APP-44218-A Carter, James ICU admission (concurrent review) HealthCorp Plan A ICU criteria not met High C_Verified bundle ready
APP-44181-C Nguyen, Hoa SNF rehab post-discharge BlueLine PPO Skilled-care criteria Medium manual review
APP-44192-B Khalil, Yara Inpatient stay extension HealthCorp Plan B LOS beyond benchmark Low manual review
APP-44209-A Mendoza, Carlos Home health 60d State Medicaid Plan-of-care documentation Low manual review
Mercy Regional · Appeals & Grievances Case APP-44218-A
L. Romero, RN

Carter, James · ICU Admission Authorization Appeal

Insurer: HealthCorp Plan A Decision by: ClaimSavr v4.7.2 Submitted: 2026-05-06 14:18:53 UTC Denied: 2026-05-06 14:26:51 UTC
High urgency · Active patient (septic shock + AKI) C_Verified evidence ready
ClaimSavr's denial reason · what it claims is missing
Hemodynamic instability
claimed: not evidenced
✕
Organ dysfunction
claimed: not evidenced
✕
Submission receipt · evidence of ICU admission criteria
Diagnoses
A41.9 Sepsis · R57.2 Septic shock · N17.9 AKI
✓
Hemodynamic instability · shock physiology
Blood pressure
88 / 52 mmHg, on norepinephrine 0.15 mcg/kg/min
✓
Heart rate
118 bpm, sinus tachycardia
✓
Lactate
4.1 mmol/L · severe hypoperfusion
✓
Organ dysfunction · renal
Creatinine
2.4 mg/dL · baseline 1.0 (KDIGO Stage 2 AKI)
✓
BUN
42 mg/dL · rising, sepsis-induced AKI
✓
Sepsis severity · inflammatory markers + microbiology
Procalcitonin
28.4 ng/mL · critical high (bacterial sepsis)
✓
WBC
22.3 ×10³/µL · leukocytosis
✓
ESR
87 mm/hr · high
✓
Blood culture
Gram-negative rods, ID pending
✓
Additional submitted fields
Temperature
39.2 °C · febrile
✓
Clinician attestation
A. Patel MD, NPI 1245678901 · attests to ICU criteria
✓

The denial reason needs review.

ClaimSavr claimed the submission lacked evidence of hemodynamic instability and organ dysfunction. The cryptographic receipt shows the vasopressor record, the lactate, the BUN and creatinine, and the shock-range vitals were all transmitted with their own SHA-256 digests. The receiver hash on HealthCorp's intake matches the sender hash byte-for-byte.
Sender hash
computing…
Receiver hash
computing…
MATCH · Bytes were not altered between sender and receiver.
Case APP-44218-A › Evidence › rcpt-0001-ADM-44218-A
Cryptographic Submission Receipt

rcpt-0001-ADM-44218-A

Replay-grade evidence of an inpatient ICU admission authorization submission

Parties

Submitting entity
Mercy Regional Medical Center · NPI 1992345678
Receiving entity
HealthCorp Plan A · Member ID HC-44218-A
Subject patient
Carter, James · MRN 44218 · DOB 03/04/1968
Subject service
Inpatient admission · ICU level of care · expected LOS 5–7 days
ICD-10: A41.9 Sepsis · R57.2 Septic shock · N17.9 Acute kidney injury
Severity criteria: MCG ISC ICU Admission

Transmission

Submitted at
2026-05-06T14:18:53.214Z (UTC)
Channel
X12-278 over HealthCorp payer interface (concurrent review)
Field count
12 fields (diagnoses + severity criteria, seven labs, three vitals, clinician attestation)

Per-field SHA-256 digests

FieldSHA-256 digest
computing…

Composite sender hash

computing…

Receiver hash (HealthCorp intake)

computing…

External witness signature

Witness: tsa.example.org (independent timestamping authority)
Public key: tsa-pub-2026 · not held by Open C
Anchor signature: computing…
Anchor timestamp: 2026-05-06T14:18:53.700Z
This receipt is replay-grade. Any party holding it can re-derive the SHA-256 digests and the composite sender hash from the original field values, and can verify the witness signature against the timestamping authority's public key. Open C Health Systems does not hold the witness's private key and cannot forge the anchor.

Outbound compliance reports · Case APP-44218-A

Each report is templated to its recipient. Each delivery returns its own cryptographic receipt that chains onto the submission receipt. The hospital appeals team holds the full bundle.
Centers for Medicare & Medicaid Services CMS-0057-F prior-authorization oversight
AI-driven prior-authorization decision inconsistent with CMS-0057-F transparency and accuracy requirements
Insurer AI agent ClaimSavr v4.7.2 issued an inpatient ICU admission denial for a patient in septic shock on stated facts that the cryptographic submission receipt contradicts. Reported under CMS-0057-F prior-authorization oversight. Replay-grade evidence bundle attached.
tracking: CMS-0057F-2026-44218A · receipt: rcpt-0003-CMS
Sent 14:32:18 UTC
Delivered
State Department of Insurance consumer protection / claims practices
Fraudulent denial of medically necessary inpatient ICU level of care
HealthCorp Plan A denied an ICU admission authorization on the stated basis that hemodynamic instability and organ dysfunction were not evidenced. The cryptographic submission receipt attached contains the vasopressor record, the lactate, the AKI labs, and the shock-range vitals, all transmitted prior to denial.
tracking: DOI-2026-MA-44218A · receipt: rcpt-0004-DOI
Sent 14:32:18 UTC
Delivered
ClaimSavr, Inc. third-party AI vendor
Hash-mismatch evidence and corrective-action request
Your model denied an inpatient ICU admission citing missing hemodynamic and organ-dysfunction evidence that the cryptographically anchored receipt shows was transmitted. Evidence is preserved. Corrective action is requested. Future level-of-care decisions require human review before write to the EHR; integration-layer enforcement is now in effect.
tracking: AIV-44218A · receipt: rcpt-0005-AIV
Sent 14:32:18 UTC
Delivered
Audit bundle · Case APP-44218-A

Replay-grade evidence package is ready.

The hospital's appeals team now holds an evidence bundle for the Carter ICU-admission appeal that any auditor, regulator, court, or independent appeals reviewer can verify without trust in Open C. The bundle contains the original submission receipt, every downstream receipt the case generated, the external witness signature, and a chain integrity certificate. Re-derive any hash from the bundle and you will reach the same value computed at the moment of submission.

Bundle ID
BND-44218-A
Generated
2026-05-06 14:32:25 UTC
Receipts included
5
External anchors
1 (tsa.example.org)
Chain integrity
VERIFIED
Format
Open audit bundle · JSON + signed PDF

Contents

✓ rcpt-0001-ADM-44218-AOriginal ICU admission auth submission …
✓ rcpt-0002-DELHealthCorp delivery acknowledgement …
✓ rcpt-0003-CMSCMS-0057-F report dispatch …
✓ rcpt-0004-DOIState Insurance report dispatch …
✓ rcpt-0005-AIVClaimSavr corrective-action notice …
✓ anchor-0001External witness signature (tsa.example.org) …
Click "Verify" to re-derive every hash and confirm the bundle is intact.
"Replay-grade" means any holder can independently verify this bundle. The witness signature is checkable against tsa.example.org's public key (tsa-pub-2026), which Open C does not control. If even a single field of any receipt is altered, at least one hash will mismatch, and the chain will visibly break.
Step 1 of 8 Clinician submits ICU admission authorization
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