# Agentic Governance and Adversarial Verification for Policy-Constrained LLM Healthcare Appeal Generation

arXiv: https://arxiv.org/abs/2609.27844 · HTML: https://mlsanity.com/paper/2609.27844/

## Key facts

- No citing papers in the map yet (data through 14 Oct 2026).
- Placed in Medical and scientific domain agents, one of 16 directions in LLM agents and tool use.
- Builds on 5 of its 12 references that are in the map.
- First posted on arXiv 20 Aug 2026.

## Placed in

- LLM agents and tool use / [Medical and scientific domain agents](https://mlsanity.com/agents/medical-and-scientific-domain-agents/)

## Builds on (most cited first, 5 of 5)

- [Retrieval-Augmented Generation for Knowledge-Intensive NLP Tasks](https://mlsanity.com/paper/2005.11401/) (2020)
- [Self-Refine: Iterative Refinement with Self-Feedback](https://mlsanity.com/paper/2303.17651/) (2023)
- [Improving Factuality and Reasoning in Language Models through Multiagent Debate](https://mlsanity.com/paper/2305.14325/) (2023)
- [From Local to Global: A Graph RAG Approach to Query-Focused Summarization](https://mlsanity.com/paper/2404.16130/) (2024)
- [RAPTOR: Recursive Abstractive Processing for Tree-Organized Retrieval](https://mlsanity.com/paper/2401.18059/) (2024)

## Abstract (arXiv)

Claim denial management costs U.S. healthcare approximately 260 billion annually in administrative overhead. Large Language Models (LLMs) and Retrieval-Augmented Generation (RAG) can produce fluent clinical text, but single-agent architectures fail in high-stakes healthcare: they introduce unsupported clinical details and lose the logical structure of hierarchical payer policy. We propose AGVF (Agentic Governance and Adversarial Verification Framework), a multi-agent architecture for medical-necessity appeal generation under explicit policy and evidence constraints. AGVF models appeal synthesis as a Constrained Markov Decision Process (CMDP) over five agents: policy formalization, evidence retrieval, gap analysis, adversarial critique, and gated synthesis. We prove that refinement over a fixed policy constraint graph monotonically reduces evidence-deficiency and terminates with either a complete satisfying frontier or a localized evidence gap. A deterministic citation- grounding gate prevents assertions without admissible evidence from entering shared state. We provide a reference implementation and validate it on 1,000 synthetic appeal cases parameterized from de-identified public hospital discharge data. The validation confirms zero citation-grounding violations across all AGVF cases and monotone deficiency reduction in every episode; ablating the gate raises violations to 100%, confirming it is load-bearing. The study uses no real patient records and does not measure clinical efficacy. AGVF thus contributes a theory-backed agentic architecture and verified reference implementation for policy-constrained LLM generation in healthcare.