118 case types. Every one runs on a published rulebook and a named referee.
We screen a case type on 3 tests before we build for it: the work is document-driven, a named rulebook defines the correct output, and a named referee grades it on a known clock. These 118 pass, each with its own page naming that rulebook and referee outright, so you can check the standard before you send a file.
SSA disability — ALJ hearing prep, CDRs, DDS →
Rulebook: 20 CFR Pt 404 Subpt P App 1 (Blue Book Listings) + App 2 (Medical-Vocational Grids).
Referee: ALJ → Appeals Council → US District Court, where the substantial-evidence standard means a decision failing to address material evidence gets remanded.
SSA consultative examination (CE) vendor market →
Rulebook: 20 CFR §404.1519 through §404.1519t and §416.919 — the rules governing when a consultative examination is purchased, who may perform it, and what the report must contain.
Referee: The state Disability Determination Services examiner, who returns reports that fail the §404.1519n content requirements.
Litigation funding / mass tort portfolio underwriting →
Rulebook: The funder's own underwriting matrix (advance ≤10-20% of anticipated settlement value, gridded by injury type/treatment level/venue); state consumer-lending law.
Referee: The case settles for a number. Underwritten value vs. realized value is measured on every deal, and portfolio default rate is reported to the funder's own investors.
Personal injury medical specials (billed versus paid) →
Rulebook: Fed. R. Civ. P. 26(a)(1)(A)(iii) damages computation, the forum’s pattern jury instructions on medical expenses, and its billed-versus-paid rule.
Referee: The adjuster reconciling the figure against the bills, then the trial court on a motion in limine over which amounts reach the jury.
Treating physician and expert causation disclosures →
Rulebook: Fed. R. Civ. P. 26(a)(2)(B) and (C) disclosure requirements, read against Fed. R. Evid. 702 as amended in December 2023.
Referee: The trial court at a Rule 702 hearing, which excludes an opinion the reviewed record does not support.
Motor vehicle accident injury claims (no-fault and threshold) →
Rulebook: The forum state’s no-fault or PIP statute (N.Y. Ins. Law §5102 and 11 NYCRR 65-3, Fla. Stat. §627.736, Mich. Comp. Laws §500.3107) and the serious injury threshold at §5102(d).
Referee: The carrier’s no-fault examiner and peer reviewer, then the trial court on a threshold motion, then the BCRC pricing conditional payments from the treatment record.
Trucking accident — plaintiff injury and driver qualification →
Rulebook: 49 CFR Part 391 Subpart E, §§391.41-391.49, with the FMCSA Medical Examiner Handbook and the National Registry that govern who may certify the driver.
Referee: The certified medical examiner whose report the qualification file either contains or does not, FMCSA on the file itself, and the trial court on negligent qualification.
Premises liability slip, trip and fall →
Rulebook: ASTM F1637 and ANSI/ASSP A1264.2 on walking surfaces, the forum’s comparative fault statute, and the Medicare Secondary Payer rules at 42 CFR Part 411 Subpart B.
Referee: The defense medical examiner on pre-existing findings and gaps, then the trial court at summary judgment on whether the record supports the pled mechanism.
Maritime and aviation injury (Jones Act seamen and aircrew) →
Rulebook: The Jones Act at 46 U.S.C. §30104 with maintenance and cure and unseaworthiness, the McCorpen concealment defense, and the medical certification rules at 46 CFR Part 10 and 14 CFR Part 67.
Referee: The federal district court sitting in admiralty on the concealment defense, the employer’s adjuster terminating maintenance and cure at maximum medical improvement.
Motorcycle accident injury claims →
Rulebook: The forum state’s helmet law and comparative fault statute, read against the ED toxicology and the head, spine and orthopedic record.
Referee: The liability adjuster on helmet use and gaps in care, then the trial court on whether helmet non-use reaches the jury.
Uber and Lyft rideshare accident claims →
Rulebook: Cal. Pub. Util. Code §5433 and the other state TNC insurance statutes, which set the coverage by app period.
Referee: The TNC’s insurer deciding which app period the driver was in, then the trial court on coverage and damages.
Boat and recreational vessel accident injury →
Rulebook: Coast Guard casualty reporting at 46 CFR §4.05-10, post-casualty chemical testing at 46 CFR §4.06-3, and the 3-year limit at 46 U.S.C. §30106.
Referee: The federal district court sitting in admiralty, and the Coast Guard investigating officer on the casualty report.
Dog bite injury claims →
Rulebook: The forum’s dog bite statute or one-bite rule, and the CDC rabies guidance on the 10-day observation and postexposure prophylaxis.
Referee: The homeowners or renters insurer’s adjuster, then the trial court on liability and the scarring and emotional injury claimed.
Train accident and FELA railroad worker claims →
Rulebook: The Federal Employers’ Liability Act, 45 U.S.C. §§51-60, with the 3-year limit at §56, the safety statute rule at §53, and FRA injury reporting at 49 CFR Part 225.
Referee: The railroad’s claim agent working the company medical file, then the jury in state or federal court.
CATASTROPHIC INJURY & WRONGFUL DEATH
7Catastrophic injury life care plan foundations →
Rulebook: The International Academy of Life Care Planners Standards of Practice, which require every plan item to rest on the record or a treating recommendation.
Referee: The court at a Rule 702 hearing, the opposing life care planner working item by item, and the economist reducing the plan to present value.
Traumatic brain injury, mild and severe →
Rulebook: The ACRM 2023 diagnostic criteria for mild traumatic brain injury and the VA and DoD clinical practice guideline, against the charted GCS and PTA.
Referee: The defense neuropsychologist reading the same chart, and the court at a Rule 702 hearing on diagnosis and permanence.
Wrongful death and survival actions →
Rulebook: The forum’s wrongful death and survival statutes, the NCHS Physicians’ Handbook on Medical Certification of Death, and the NAME autopsy performance standards.
Referee: The certifying physician or medical examiner, then the court on any expert opinion that departs from the certified cause of death.
Sports concussion and CTE exposure histories →
Rulebook: The NFL Concussion Settlement’s Qualifying Diagnoses and Baseline Assessment Program protocol, the Amsterdam 2023 consensus statement, and the NINDS criteria for traumatic encephalopathy syndrome.
Referee: The settlement Claims Administrator and the court-appointed Special Master, and the qualified BAP provider, a board-certified neuropsychologist or neurologist.
Amputation and limb loss injury →
Rulebook: The limb salvage record scored against the Mangled Extremity Severity Score, and Medicare’s K-level classification in LCD L33787 for the prosthesis.
Referee: The opposing life care planner pricing each prosthesis and replacement, and the court on the future care the record supports.
Crush injury, compartment syndrome and rhabdomyolysis →
Rulebook: The charted compartment pressures, CK and kidney labs, read against the clinical thresholds for fasciotomy and rhabdomyolysis.
Referee: The defense surgical expert on fasciotomy timing, then the court at a Rule 702 hearing.
Burn injury, TBSA and grafting course →
Rulebook: The American Burn Association referral criteria, the rule of nines and Lund-Browder charts for TBSA, and the Parkland fluid formula.
Referee: The defense burn expert reading each TBSA estimate, then the opposing life care planner on grafting and scar care.
VA C&P exam contractors (MDE program) →
Rulebook: 38 CFR Part 4 Schedule for Rating Disabilities (each diagnostic code has explicit criteria); 38 CFR §3.303/3.304/3.307/3.309; §4.2 inadequate-exam standard.
Referee: MDEO's 10-question Quality Criteria Checklist, sampled quarterly; contract SLAs impose financial penalties for error rates above threshold.
Camp Lejeune Justice Act — Elective Option tiers →
Rulebook: DOJ/DON Public Guidance on the Elective Option — a 3x2 grid by exposure duration and injury tier.
Referee: Navy Camp Lejeune Claims Unit checks documentation sufficiency against the chart; DOJ Torts Branch authorizes; claimant has 60 days to accept.
9/11 Victim Compensation Fund + WTC Health Program →
Rulebook: Zadroga Act (as amended, authorized through 2090); 28 CFR Part 104; VCF Policies & Procedures; 42 CFR Part 88 WTCHP.
Referee: 2-stage government grading — NIOSH/WTCHP certifies the condition (or denies, with appeal), then the VCF Special Master issues a separate written eligibility decision.
VA nexus letter evidence timelines →
Rulebook: 38 CFR §3.303(d) and §3.310 on direct and secondary service connection, §3.102 on benefit of the doubt, and the M21-1 guidance on what makes a private opinion adequate.
Referee: The rating VSR weighing the private opinion against the C&P examiner’s, then the Board of Veterans’ Appeals, then the Court of Appeals for Veterans Claims.
PACT Act and toxic exposure presumptive claims →
Rulebook: 38 U.S.C. §1119 and §1120 added by the PACT Act, the particulate matter presumptives at 38 CFR §3.320, the general presumptive rules at §3.307 and §3.309, and the M21-1.
Referee: The rating VSR matching the diagnosis to the presumptive list and the service dates to the covered locations, then the Board and the Court of Appeals for Veterans Claims.
State workers' comp impairment rating (AMA Guides) →
Rulebook: Deliberately fragmented by state — ~18 states + FECA + DBA use AMA Guides 6th; California uses 5th (Lab Code §4660).
Referee: State WC judge / appeals board accepts or rejects; opposing party buys a rebuttal IME. In Texas the Designated Doctor's opinion carries presumptive weight.
OWCP / FECA — Statement of Accepted Facts →
Rulebook: 5 USC §8101 et seq; 20 CFR Part 10; FECA Procedure Manual Parts 2 & 3; AMA Guides 6th ed mandatory for schedule awards.
Referee: The Employees' Compensation Appeals Board routinely vacates decisions when the SOAF was incomplete or omitted a material fact.
Black Lung Benefits Act →
Rulebook: 20 CFR Part 718 — Appendices A-C specify exact PFT and ABG numeric thresholds by height and age; 30 USC §921(c)(4) 15-year rebuttable presumption.
Referee: District Director → DOL OALJ → Benefits Review Board → Court of Appeals; a mis-selected exhibit is fatal to the appeal. Approval rate roughly a third.
EEOICPA Parts B & E (energy employees) →
Rulebook: 20 CFR Part 30; 42 CFR Part 82 (dose reconstruction) and Part 81 (IREP probability of causation — ≥50% PoC is compensable, a literal statistical model).
Referee: District Office Recommended Decision → Final Adjudication Branch hearing → written findings on each contested fact → district court.
California IMR / workers' comp utilization review →
Rulebook: Labor Code §4610 / §4610.5-4610.6; 8 CCR §9792.6-9792.12; MTUS incorporating ACOEM Practice Guidelines + MTUS Drug Formulary.
Referee: Maximus issues a written determination with an explicit guideline citation, and DWC publishes the statewide overturn rate annually.
RECA — Radiation Exposure Compensation Act (reauthorized) →
Rulebook: 42 USC §2210 note; 28 CFR Part 79, enumerating by disease exactly what pathology/diagnostic evidence is acceptable; reauthorized 2025.
Referee: DOJ Civil Division issues a written approval or denial specifying the evidentiary deficiency, with administrative appeal and re-filing — binary and itemized.
Longshore (LHWCA) & Defense Base Act →
Rulebook: 33 USC §901 et seq; 42 USC §1651 (DBA); 20 CFR Parts 701-704, 702; §908(c)(13)(E) statutorily mandates the AMA Guides for hearing loss.
Referee: District Director informal conference → DOL OALJ formal hearing → Benefits Review Board → Court of Appeals, each producing a written decision.
Occupational disease and repetitive stress claims →
Rulebook: The forum state’s occupational disease statute and its onset-based limitations clock, the adopted edition of the AMA Guides, OSHA work-relatedness at 29 CFR §1904.5, and NIOSH criteria documents.
Referee: The workers’ compensation administrative law judge deciding work-relatedness and onset, with the treating physician and the evaluator rating impairment under the adopted Guides.
Rule 35 defense medical examinations →
Rulebook: Fed. R. Civ. P. 35(a) good cause and conditions in controversy, 35(b) the examined party’s right to the report, and state analogues such as California CCP §2032.
Referee: The trial court deciding the Rule 35 motion and ruling on an examination that exceeded the order, and plaintiff’s counsel moving to strike.
Auto no-fault IME and peer review packets →
Rulebook: New York’s 11 NYCRR Part 65-3 and its 30-day clock, Michigan’s MCL 500.3151, and Florida Statutes §627.736(7).
Referee: The no-fault arbitrator reviewing the denial and the report behind it, and the state department of insurance on a market conduct examination.
California QME / AME med-legal record review →
Rulebook: 8 CCR §9793-9795 Medical-Legal Fee Schedule; Lab Code §4628, §4062.3; AMA Guides 5th ed (CA is locked to 5th).
Referee: Claims admin can refuse payment; QME deposed (ML204 $455/hr); WCAB judge accepts or rejects as substantial medical evidence.
Mass tort settlement matrix scoring (claims administration) →
Rulebook: Court-approved Allocation Methodology / MSA exhibits + Case Management Orders (e.g. point-grid injury matrices).
Referee: Claims Administrator scores → reconsideration → court-appointed Allocation Special Master re-review → defendant audit rights.
Asbestos bankruptcy trust claims (TDP packages) →
Rulebook: Each trust's own Trust Distribution Procedures — a literal disease-level payment table.
Referee: Trust claims-processing facility grades against the TDP grid; trusts run statistical audits and can suspend a firm's filing privileges.
VICP — vaccine injury compensation ('vaccine court') →
Rulebook: Vaccine Injury Table, 42 CFR §100.3 — a literal 3-column table (vaccine, injury, time interval for onset).
Referee: Special Masters of the US Court of Federal Claims, in written, published, citable decisions, reviewable by a CFC judge then the Federal Circuit.
Sexual abuse survivor trusts & diocesan claims programs →
Rulebook: Trust Distribution Procedures + Claims Matrix — tiers by act severity, each with a base and maximum value, plus aggravating factors.
Referee: A named Claims Administrator under a retired federal judge as Trustee, with an Independent Reviewer role adjudicating disputes.
MDL plaintiff fact sheets and census registries →
Rulebook: The MDL’s case management order and the fact sheet form attached to it, enforceable under Fed. R. Civ. P. 16 and sanctionable under Rule 37.
Referee: The transferee judge on a show-cause dismissal docket, the special master issuing deficiency notices, and defense liaison counsel auditing sheets.
Product liability medical causation →
Rulebook: Fed. R. Evid. 702 as amended in December 2023, the Reference Manual on Scientific Evidence, and the product labeling in force during the exposure window.
Referee: The court at a Daubert hearing on general and specific causation, and the defense causation expert working the same chart.
Toxic tort exposure, general and specific causation →
Rulebook: Federal Rule of Evidence 702 as amended December 2023 and the general versus specific causation split, the Reference Manual on Scientific Evidence third edition, and Restatement (Third) of Torts §28.
Referee: The trial court at a Rule 702 hearing and, in an MDL, the transferee judge deciding general causation for every case at once, with the defense toxicologist reading the same file.
Pharmaceutical drug injury claims →
Rulebook: The label in force during use, FDA adverse event reporting at 21 CFR §314.80, and Fed. R. Evid. 702 as amended in December 2023.
Referee: The MDL transferee judge under 28 U.S.C. §1407 on general causation, and the defense expert on every other cause.
Benzene sunscreen and aerosol product claims →
Rulebook: FDA’s 2 ppm limit for benzene in drug products (ICH Q3C), the product and lot numbers used, and the IARC Group 1 classification.
Referee: The court at a Rule 702 hearing on specific causation, and the defense toxicologist on other benzene exposures.
Chemical hair relaxer cancer claims →
Rulebook: The case management orders and fact sheet in MDL No. 3060, read against the Sister Study use-frequency findings (Chang et al., JNCI 2022).
Referee: The transferee judge in the Northern District of Illinois, and the defense expert on other gynecologic risk factors.
Philips CPAP recall injury claims →
Rulebook: The June 2021 recall, the device serial number and usage downloads, and the terms of the MDL No. 3014 personal injury settlement.
Referee: The settlement claims administrator on eligibility, and the transferee judge in the Western District of Pennsylvania.
State medical board licensure investigations →
Rulebook: The state medical practice act and the board's own regulations, which define unprofessional conduct and the documentation a licensee must keep.
Referee: The board's investigator and its expert reviewer, who read the charts and write the report the board votes on.
Hospital peer review, OPPE / FPPE & credentialing →
Rulebook: The Joint Commission Medical Staff standards requiring ongoing professional practice evaluation (OPPE) and focused professional practice evaluation (FPPE) for every privilege granted.
Referee: The peer review or medical executive committee, which votes on the finding and the privilege recommendation.
RCA / sentinel event review / Patient Safety Organizations →
Rulebook: The Joint Commission Sentinel Event Policy, which requires a comprehensive systematic analysis and an action plan, generally within 45 days of the event becoming known.
Referee: The Joint Commission, which reviews the thoroughness and credibility of the analysis and the action plan.
Birth injury and neonatal encephalopathy →
Rulebook: The ACOG and AAP report Neonatal Encephalopathy and Neurologic Outcome, second edition, and the ACOG bulletins adopting the NICHD 3-tier fetal heart rate categories.
Referee: Retained maternal-fetal medicine and neonatology experts, the court at a Rule 702 hearing, or a state birth-injury program panel such as Florida’s NICA.
Emergency department failure to diagnose →
Rulebook: EMTALA at 42 U.S.C. §1395dd and 42 CFR §489.24, the Emergency Severity Index triage handbook, and the department’s own protocols produced in discovery.
Referee: CMS and the Office of Inspector General on an EMTALA complaint, the state survey agency, and the court on the negligence claim.
Surgical error and retained item claims →
Rulebook: 42 CFR §482.51(b)(6) and §482.52 on operative and anesthesia records, the Joint Commission Universal Protocol and NPSG.01.01.01, and the AORN surgical counts guideline.
Referee: The trial court on the certificate of merit and again at a Rule 702 hearing, with the state medical board and hospital peer review reading the same record.
Medication and dosing error claims →
Rulebook: 42 CFR §482.23(c) and §482.25 on drug administration, NPSG.03.06.01 on reconciliation, and the ISMP High-Alert Medications and Confused Drug Names lists.
Referee: The trial court on the certificate of merit and at a Rule 702 hearing, plus the state boards of pharmacy and medicine on the same administration record.
Hospital and nursing negligence, failure to rescue →
Rulebook: The nursing services condition of participation at 42 CFR §482.23, AHRQ Patient Safety Indicator 04 on failure to rescue, the state nurse practice act, and the certificate of merit statute.
Referee: The trial court on the certificate of merit and again at a Rule 702 hearing, with the state board of nursing and the CMS surveyor reading the same chart.
LONG-TERM CARE & ELDER
2Nursing home neglect and elder care claims →
Rulebook: 42 CFR Part 483 Subpart B, converted into surveyable F-tags by the CMS State Operations Manual Appendix PP, plus the MDS 3.0 RAI manual.
Referee: The state survey agency citing F-tags at a scope and severity level, CMS imposing remedies, and the court on the neglect action.
Guardianship and conservatorship capacity petitions →
Rulebook: The forum’s guardianship code and its required evaluator certificate, framed functionally where the Uniform Guardianship Act has been adopted.
Referee: The probate court granting, limiting or denying the petition, and the court visitor or guardian ad litem reporting independently.
Pennsylvania certificate of merit (Rule 1042.3) →
Rulebook: Pa. R.C.P. 1042.3, which requires a certificate with the complaint or within 60 days, in one of 3 alternative forms.
Referee: The court of common pleas, which enters judgment of non pros on praecipe under Rule 1042.7 once the Rule 1042.6 notice has run.
Texas Chapter 74 expert report →
Rulebook: Tex. Civ. Prac. & Rem. Code §74.351, which requires a served expert report and CV carrying the 3 opinions named in subsection (r)(6).
Referee: The trial court, which dismisses with prejudice and awards attorney's fees if no report is served within 120 days of a defendant's answer.
Florida presuit medical expert opinion →
Rulebook: Fla. Stat. §766.203(2), which requires a verified written medical expert opinion corroborating reasonable grounds, served with the notice of intent.
Referee: The court on a §766.206 presuit review, which may dismiss the claim or report counsel to The Florida Bar.
Georgia §9-11-9.1 expert affidavit →
Rulebook: O.C.G.A. §9-11-9.1, which requires an affidavit setting out at least one negligent act or omission and the factual basis for it.
Referee: The trial court, which dismisses under §9-11-9.1(e) unless the affidavit was filed or the (b) grace period applies.
Illinois 2-622 affidavit and written report →
Rulebook: 735 ILCS 5/2-622, which requires an attorney affidavit plus a separate written health-professional report for each defendant named.
Referee: The circuit court, which dismisses under 735 ILCS 5/2-619 where the report is missing or the reviewer is not qualified under 5/8-2501.
Michigan affidavit of merit (MCL 600.2912d) →
Rulebook: MCL 600.2912d, which requires an affidavit signed by a health professional who meets the MCL 600.2169 matching requirements.
Referee: The circuit court, which treats a complaint filed without a conforming affidavit as failing to toll the limitations period.
Ohio affidavit of merit (Civ. R. 10(D)(2)) →
Rulebook: Ohio Civ. R. 10(D)(2), which requires one affidavit relative to each defendant, from an affiant who attests they reviewed the applicable medical records.
Referee: The court of common pleas, which dismisses under 10(D)(2)(d) where no conforming affidavit or extension motion was filed.
North Carolina Rule 9(j) certification →
Rulebook: N.C. R. Civ. P. 9(j), which requires the complaint itself to assert that the records reasonably available were reviewed by a person reasonably expected to qualify.
Referee: The superior court, which dismisses a complaint lacking the certification and has no discretion to excuse it.
New Jersey affidavit of merit (2A:53A-27) →
Rulebook: N.J.S.A. 2A:53A-27, which requires an affidavit from an appropriately licensed person within 60 days of the answer, specialty-matched under the Patients First Act.
Referee: The Law Division at the Ferreira conference, where a missing affidavit is treated under 2A:53A-29 as a failure to state a cause of action.
Delaware affidavit of merit (18 Del. C. §6853) →
Rulebook: 18 Del. C. §6853, which requires an affidavit of merit and the expert's current CV filed under seal with the complaint.
Referee: The Superior Court prothonotary, who will not docket a healthcare negligence complaint that arrives without the affidavit.
MEDICAL EXAMINER SERVICES
2Medical examiner / coroner case review + NVDRS →
Rulebook: The US Standard Certificate of Death and the CDC/NCHS cause-of-death certification guidance, which define the causal sequence and the manner categories.
Referee: The certifying pathologist, whose signature carries the cause and manner determination.
Maternal mortality & fatality review committees →
Rulebook: The CDC Maternal Mortality Review Information Application (MMRIA) data dictionary, which defines the case narrative structure and every coded field.
Referee: The maternal mortality review committee, which votes on pregnancy-relatedness, preventability, and contributing factors.
FORENSIC EVALUATION
8Emotional and psychological damages (civil) →
Rulebook: The forum’s tort law on emotional distress damages including any physical injury or zone of danger requirement, DSM-5-TR criteria, and Rule 702 as amended December 2023.
Referee: The trial court at a Rule 702 hearing, the opposing retained psychologist reading the same chart for the pre-incident entries, and the jury on cross-examination.
Competency to stand trial (Dusky) →
Rulebook: Dusky v. United States, 362 U.S. 402 (1960), the forum’s competency statute and its restoration clock bounded by Jackson v. Indiana, Sell v. United States on involuntary medication, and the AAPL practice guideline.
Referee: The criminal court finding the defendant competent, incompetent and restorable, or neither, with the state forensic hospital reading the medication and behavioural record it was sent.
Criminal responsibility and mental state at the offense →
Rulebook: The forum’s insanity standard, whether M’Naghten, ALI Model Penal Code §4.01, a guilty but mentally ill statute or 18 U.S.C. §17, with Rule 704(b) and Ake v. Oklahoma, 470 U.S. 68 (1985).
Referee: The jury, which decides the mental state question the expert is barred from answering directly, with the trial court under Rules 702 and 704(b) and the prosecution’s rebuttal evaluator.
Capital and sentencing mitigation life histories →
Rulebook: Wiggins v. Smith, 539 U.S. 510 (2003) and Williams v. Taylor on the reasonableness of the life-history investigation, the ABA death penalty defense guidelines 10.7 and the Supplementary Mitigation Guidelines, and Atkins v. Virginia with Hall and Moore.
Referee: The sentencing jury or judge, then the post-conviction or habeas court on ineffective assistance, reading what the records contained against what the jury was told.
Child custody and parental fitness evaluations →
Rulebook: The forum’s best-interests statute and its enumerated factors, the AFCC Model Standards of Practice for Child Custody Evaluation, the APA custody evaluation guidelines, and the court’s own appointment order.
Referee: The family court adopting, modifying or rejecting the recommendation, the guardian ad litem reading the records independently, and any second-opinion reviewer retained to critique the report.
Fitness for duty and return-to-work evaluations →
Rulebook: The ADA medical inquiry limit at 42 U.S.C. §12112(d)(4) with the EEOC enforcement guidance on disability-related inquiries, the employer’s published fitness standard, and 49 CFR Part 391 Subpart E or 14 CFR Part 67 where the role is regulated.
Referee: The employer or agency making the return-to-work or removal decision, the licensing board on a practitioner referral, and the arbitrator or the EEOC where the inquiry is challenged as too broad.
Violence and sexual offence risk, SVP commitment →
Rulebook: The forum’s sexually violent predator statute of the kind upheld in Kansas v. Hendricks, 521 U.S. 346 (1997), or 18 U.S.C. §4248, read with the Static-99R coding rules and the HCR-20 Version 3 item definitions.
Referee: The commitment court or parole board ordering release, commitment or continued detention, with the respondent’s evaluator rescoring the same items from the same file.
Symptom validity and malingering collateral records →
Rulebook: The Slick, Sherman and Iverson criteria for malingered neurocognitive dysfunction, the AACN consensus statement on effort and response bias, the TOMM and MMPI-3 manuals, and Rule 702 as amended December 2023.
Referee: The opposing expert reading the same chart for the entries a validity opinion failed to address, the trial court at a Rule 702 hearing, and the claims examiner relying on the finding.
CIVIL RIGHTS & IMMIGRATION
5Asylum medical-legal affidavits (Istanbul Protocol) →
Rulebook: The Istanbul Protocol, 2022 edition, including its consistency terminology, read with 8 CFR §208.13 and the corroboration provisions at 8 U.S.C. §1158(b)(1)(B).
Referee: The USCIS asylum officer at the affirmative interview, then the immigration judge at EOIR and the Board of Immigration Appeals on the same affidavit.
Naturalization disability waiver (Form N-648) →
Rulebook: 8 CFR §312.2(b), the Form N-648 instructions on who may certify and how the nexus has to be stated, and USCIS Policy Manual Volume 12, Part E.
Referee: The USCIS officer at the naturalization interview, who accepts the certification, requests evidence, or proceeds with the full English and civics test.
Police use-of-force and in-custody injury →
Rulebook: 42 U.S.C. §1983 and the objective reasonableness standard of Graham v. Connor, with the Istanbul Protocol and, in death cases, the Minnesota Protocol and NAME autopsy standards.
Referee: The federal district court at summary judgment on qualified immunity, the medical examiner on manner of death, and any consent decree monitor reading across incidents.
Prisoner medical neglect (Section 1983) →
Rulebook: The Eighth Amendment deliberate indifference standard of Estelle v. Gamble and Farmer v. Brennan under 42 U.S.C. §1983, the NCCHC jail and prison health standards, and PLRA exhaustion at 42 U.S.C. §1997e(a).
Referee: The federal district court at summary judgment on qualified immunity, NCCHC surveyors and any consent decree monitor, and the medical examiner in a death in custody.
Domestic violence and strangulation injury documentation →
Rulebook: The forum’s domestic violence and non-fatal strangulation statutes, the Training Institute on Strangulation Prevention documentation and imaging protocol, and the IAFN forensic nursing standards.
Referee: The prosecutor and the criminal court on a strangulation charge, the family court on a protective order or custody modification, and the civil jury where it is pled as an intentional tort.
ERISA / long-term disability claim file review & appeals →
Rulebook: 29 CFR §2560.503-1 full-and-fair-review (2018 amendments require the plan to address every piece of evidence); ERISA §502(a)(1)(B).
Referee: A federal judge, on the administrative record, in a written opinion — plus DOL/EBSA audits.
Long-term care insurance — claims eligibility & recertification →
Rulebook: IRC §7702B(c), the federal statutory definition of "chronically ill individual" (2-of-6 ADLs / 90 days / severe cognitive impairment).
Referee: Denial → internal appeal → independent third-party review (mandated in many states) → DOI complaint → litigation.
IROs / state-mandated external appeals →
Rulebook: 45 CFR 147.136; NAIC Uniform Health Carrier External Review Model Act; state IRO statutes.
Referee: State DOI audits of IRO decision files; URAC re-accreditation every 3 years; published overturn-rate databases.
FMLA / ADA accommodation medical certification review →
Rulebook: 29 CFR §825.305 through §825.308 — the certification, authentication, clarification, second and third opinion rules, and the recertification limits.
Referee: The Department of Labor Wage and Hour Division, which investigates interference and retaliation complaints.
Lien resolution & Medicare Secondary Payer compliance →
Rulebook: 42 USC §1395y(b) + 42 CFR Part 411; Ahlborn (2006) & Gallardo (2022) for Medicaid; ERISA §502(a)(3); Section 111 reporting.
Referee: CMS BCRC/CRC accepts or rejects every disputed line in writing, then a 5-level appeal ladder.
Medicare Set-Aside (WCMSA / LMSA) allocation →
Rulebook: CMS WCMSA Reference Guide v4.x; 42 USC §1395y(b); 42 CFR §411; CDC Life Table Table 1; Section 111 reporting.
Referee: CMS Workers' Comp Review Contractor (Capitol Bridge) issues a written approval or counter-higher with a dollar number.
Structured settlement rated-age underwriting →
Rulebook: Each carrier's substandard annuity manual (debit table over 2012 IAM / a2000 with an improvement scale); 50-state structured settlement protection acts.
Referee: Submit one packet, get 4-8 independent rated ages back within 24-72 hours — the carrier spread is a direct quality score on the packet.
Life insurance underwriting — APS summarization →
Rulebook: The carrier's own underwriting manual — Swiss Re Life Guide, Munich Re ALLFINANZ/MIRA, RGA GUM, Gen Re GUM — literal debit/credit tables.
Referee: Post-issue audit, mortality slippage tracking, and reinsurance treaty audits.
Life settlement / viatical life expectancy underwriting →
Rulebook: 2015 VBT / 2008 VBT base tables; ASOP No. 48 (Life Settlement Mortality); AM Best rating criteria require at least 2 independent LE providers.
Referee: The insured either dies or doesn't — every LE is graded by an Actual-to-Expected deaths ratio computed by third-party auditors.
Life claims contestability / rescission review →
Rulebook: The incontestability clause (statutory 2-year period in every state); state materiality standards.
Referee: Rescission is challenged in court whenever economically worthwhile; courts issue written opinions on materiality, and ACLI publishes scoreboard data.
Medical stop-loss / shock-claim underwriting →
Rulebook: The carrier's own disclosure form and underwriting manual, which define what must be disclosed and how a large claimant is evaluated.
Referee: The stop-loss underwriter, who prices the layer and sets any laser.
Insurance SIU — medical provider fraud & staged accidents →
Rulebook: State insurance fraud statutes and mandatory referral rules (e.g. NY 11 NYCRR 86, CA Ins. Code §1872.4, FL §626.989); NAIC Model #680.
Referee: Criminal referral → indictment → conviction; civil RICO recovery; state DOI fraud-bureau disposition statistics published annually.
No Surprises Act Independent Dispute Resolution (IDR) →
Rulebook: 45 CFR §149.510(c)(4)(iii)(C): level of training/experience/quality outcomes, patient acuity/complexity, teaching status/case mix.
Referee: The IDRE picks one of 2 offers — binary, in writing, within days — and CMS publishes every determination in quarterly reports.
Medicare audit response — TPE, UPIC, SMRC, RAC, ADR →
Rulebook: CMS Program Integrity Manual (Pub. 100-08) Ch. 3 & 8 — the 45-day ADR clock.
Referee: Contractor decision, then the 5-level appeal ladder: MAC redetermination → QIC reconsideration → OMHA ALJ → Medicare Appeals Council → federal court.
DRG downgrade / clinical validation appeals →
Rulebook: The ICD-10-CM Official Guidelines for Coding and Reporting, which govern when a diagnosis may be coded from the record.
Referee: The payer's medical director, who decides the first-level appeal.
CMS RADV audit response →
Rulebook: The CMS RADV medical record reviewer guidance, which defines an acceptable record: valid provider type, face-to-face encounter, date of service in the data year, and a legible signature and credential.
Referee: The CMS RADV medical record reviewer, who accepts or rejects each submitted record.
HCC risk adjustment retrospective chart review →
Rulebook: The ICD-10-CM Official Guidelines for Coding and Reporting, including the requirement that a condition be documented as monitored, evaluated, assessed or treated in a face-to-face encounter.
Referee: The CMS RADV medical record reviewer, who tests the same charts against the same guidance.
HEDIS / NCQA hybrid chart abstraction →
Rulebook: The NCQA HEDIS Technical Specifications for the measurement year, which define each measure's numerator, denominator, exclusions and allowable data sources.
Referee: The NCQA-certified HEDIS compliance auditor, who validates the medical record review and can invalidate a measure.
Payer-side payment integrity clinical review →
Rulebook: The plan's own medical policy and the licensed criteria set it names — the published screening criteria the determination must be measured against.
Referee: The plan's medical director, who makes and signs the medical necessity determination.
First-party bad faith claim handling →
Rulebook: The forum’s unfair claims settlement practices act, adopted from the NAIC model, and the claims examination standards in the NAIC Market Regulation Handbook.
Referee: The state department of insurance on a market conduct examination, and the court and jury on the bad faith count.
CLINICAL & REGULATORY PROGRAMS
15Cancer registry abstraction (CTR, NCDB, CoC) →
Rulebook: STORE (NCDB); SEER Program Coding and Staging Manual; NAACCR Data Standards; AJCC Cancer Staging Manual 8th ed.
Referee: CoC surveyor site visit every 3 years with live case review; NCDB hard-edit rejects against the published edit set.
Hospice eligibility / terminal prognosis documentation →
Rulebook: Medicare Benefit Policy Manual Ch. 9 §20; 42 CFR 418.22/418.25; disease-specific hospice LCDs.
Referee: TPE/UPIC/SMRC/RAC review decisions with published round-by-round denial rates; OIG hospice work plan.
Cardiac & stroke registry abstraction (STS, NCDR, GWTG) →
Rulebook: The STS National Database data specifications for the applicable harvest, with their own definitions and coding instructions per field.
Referee: The registry's data quality audit, which re-abstracts sampled cases and scores agreement.
Trauma registry abstraction (NTDB / TQIP) →
Rulebook: The National Trauma Data Standard data dictionary for the admission year, which defines inclusion criteria and every element.
Referee: The American College of Surgeons verification review team, which examines registry completeness and accuracy on site.
Clinical Endpoint Adjudication Committees (CEC) →
Rulebook: The adjudication charter, which defines the endpoint definitions, the required source documents, and exactly what must be redacted to preserve blinding.
Referee: The Clinical Endpoint Committee, whose blinded adjudication is the outcome of record.
SNF MDS 3.0 / PDPM validation →
Rulebook: The CMS Long-Term Care Facility RAI User's Manual, which defines every MDS item, its look-back period, and its coding instructions.
Referee: The MAC and the Supplemental Medical Review Contractor, on targeted probe and educate and on additional documentation requests.
FAA special issuance / HIMS pilot medical certification →
Rulebook: 14 CFR Part 67, which sets the medical standards for first, second and third class certificates.
Referee: The Federal Air Surgeon's office and the Aerospace Medical Certification Division, which issue, defer or deny.
Home health OASIS review →
Rulebook: The CMS OASIS Guidance Manual, which defines each item, its time point, and its response-specific instructions.
Referee: The MAC and the UPIC, on additional documentation requests and targeted probe and educate.
Correctional healthcare consent-decree chart audits →
Rulebook: The consent decree or settlement agreement itself, with its enumerated performance measures and compliance thresholds.
Referee: The court-appointed monitor, whose periodic reports state the compliance rating for each measure.
NHSN healthcare-associated infection surveillance →
Rulebook: The NHSN Patient Safety Component manual for the surveillance year, with its device-associated and procedure-associated event definitions.
Referee: The state health department's NHSN validation audit, which re-reviews charts and scores agreement.
DOT medical examiner certification (FMCSA complex certs) →
Rulebook: 49 CFR §391.41, the physical qualification standards a commercial driver must meet.
Referee: The certified medical examiner on the National Registry, who signs the certificate and stakes their listing on it.
Pharmacovigilance / ICSR case processing →
Rulebook: ICH E2B(R3), which defines the individual case safety report data elements and the narrative's place among them.
Referee: The regulator receiving the report — FDA, EMA, or the national competent authority — whose inspectors read the narrative against the source.
Medical device complaint handling & MDR reportability →
Rulebook: 21 CFR Part 803, the medical device reporting regulation, with its serious injury and malfunction definitions and its 30-day and 5-day clocks.
Referee: The FDA investigator on a QSR inspection, who reads complaint files and the reportability rationale behind each one.
Organ procurement (OPO) donor eligibility review →
Rulebook: OPTN policy, including the donor medical and behavioural history requirements and the risk criteria for disease transmission.
Referee: The OPTN and its Membership and Professional Standards Committee, which review policy compliance.
Regulatory medical writing — CSR patient narratives →
Rulebook: ICH E3, which specifies the clinical study report structure and what a patient narrative must cover.
Referee: The regulator's reviewer at submission, who reads narratives against the tabulated data.
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