add more descriptable dtq/review reasons
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1 changed files with 72 additions and 37 deletions
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@ -1,7 +1,7 @@
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from datetime import date
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from enum import Enum
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import json
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from typing import Optional
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from typing import Optional, Union
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from src.cache.drug_cache import fetch_drug_with_dosage
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from src.models import PHQ, Applicant, Plan, EstimationResponse, EstimationDetails, EstimationResult
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from src.cache.redis_cache import fetch_conditions, get_plan_by_id, search_drug
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@ -315,12 +315,12 @@ class EstimationService:
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print(f"AI DTQ Response: {response_json}")
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ai_response = json.loads(response_json)
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dtq = not ai_response["insurable"]
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reason = ai_response["reason"]
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reason = "[AI] " + ai_response["reason"]
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return dtq, reason
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except Exception as e:
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print(f"Error in AI DTQ check: {e}")
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# Fallback to not DTQ on error
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return False, ""
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# Fallback to DTQ on error
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return True, f"Error on AI service: {e}"
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def check_dtq(self, phq: PHQ) -> tuple[bool, str]:
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for medication in phq.medications:
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@ -330,26 +330,26 @@ class EstimationService:
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uninsurable_conditions = [condition["key"] for condition in uninsurable_conditions_response]
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if phq.pregnancy:
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return True, "Pregnancy"
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return True, "Applicant is pregnant"
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for issue in phq.issues:
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if issue.key == "surgery":
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for detail in issue.details:
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if detail.key == "not_performed":
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return True, "Surgery that was not performed"
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return True, "Applicant have surgery that was not performed"
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for condition in phq.conditions:
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if condition.key in uninsurable_conditions:
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return True, f"Condition: {condition.key}"
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return True, f"Applicant have uninsurable condition: {condition.key}"
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# issues would be checked by AI
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return False, None
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return False, ""
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def calculate_age(self, born):
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today = date.today()
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return today.year - born.year - ((today.month, today.day) < (born.month, born.day))
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async def calculate_rx_spend(self, phq: PHQ, applicant_id: int) -> (float, list[str]):
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async def calculate_rx_spend(self, phq: PHQ, applicant_id: int) -> tuple[float, list[str]]:
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rx_spend = 0
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review_reasons = []
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for medication in phq.medications:
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@ -391,7 +391,7 @@ class EstimationService:
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pass
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return rx_spend, review_reasons
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def get_tier(self, coverage: int, rx_spend: float) -> Optional[Tier]:
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def get_tier(self, coverage: int, rx_spend: float) -> tuple[Tier | None, str | None]:
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tiers = [
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Tier.TIER_1, Tier.TIER_15, Tier.TIER_2, Tier.TIER_25, Tier.TIER_3, Tier.TIER_35,
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Tier.TIER_4, Tier.TIER_45, Tier.TIER_5, Tier.TIER_55, Tier.TIER_6, Tier.TIER_65, Tier.TIER_7
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@ -409,9 +409,9 @@ class EstimationService:
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for i, threshold in enumerate(rates[coverage]):
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if rx_spend <= threshold:
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return tiers[i]
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return tiers[i], None
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return None
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return None, f"Rx spend ({rx_spend}) is greater than {rates[coverage][-1]} for coverage {coverage}"
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def get_plan_coverage(self, plan: Plan):
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plan_data = get_plan_by_id(plan.id)
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@ -447,10 +447,11 @@ class EstimationService:
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is_dtq, reason = self.check_dtq(phq)
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if not is_dtq:
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is_dtq, reason = await self.check_dtq_ai(phq)
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if reason:
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if is_dtq:
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dtq_reasons.append(reason)
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max_age = max(self.calculate_age(applicant.dob) for applicant in applicants)
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base_tier = None
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for base_age, tier in BASE_TIERS.items():
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if max_age <= base_age:
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base_tier = tier
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@ -459,7 +460,12 @@ class EstimationService:
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plan_coverage = self.get_plan_coverage(plans[0])
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rx_spend = 0
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for applicant_id, applicant in enumerate(applicants):
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applicant_review_reasons = []
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applicant_dtq_reasons = []
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applicant_accept_reasons = []
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applicant_age = self.calculate_age(applicant.dob)
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applicant_tier = None
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for base_age, tier in BASE_TIERS.items():
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if applicant_age <= base_age:
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applicant_tier = tier
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@ -467,25 +473,32 @@ class EstimationService:
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if applicant_age >= 65:
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is_dtq = True
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reason = "Age is over 65"
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reason = f"Applicant age {applicant_age} is over 65"
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dtq_reasons.append(reason)
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applicant_dtq_reasons.append(reason)
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if (applicant.heightFt, applicant.heightIn) in HEIGHT_WEIGHT_TABLE:
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w1, w2, w3, w4 = HEIGHT_WEIGHT_TABLE[(applicant.heightFt, applicant.heightIn)]
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if applicant.weight < w1:
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is_dtq = True
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reason = "Declined due to low BMI of one or more applicants"
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reason = f"Applicant weight {applicant.weight}lbs is less than {w1}, at height {applicant.heightFt}' {applicant.heightIn}''"
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dtq_reasons.append(reason)
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applicant_dtq_reasons.append(reason)
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elif w1 <= applicant.weight < w2:
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is_review = True
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review_reasons.append("low BMI of one or more applicants")
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weight_reason = f"Applicant weight {applicant.weight}lbs is less than {w2}, at height {applicant.heightFt}' {applicant.heightIn}''"
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review_reasons.append(weight_reason)
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applicant_review_reasons.append(weight_reason)
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elif w3 <= applicant.weight < w4:
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is_review = True
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review_reasons.append("high BMI of one or more applicants")
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weight_reason = f"Applicant weight {applicant.weight}lbs is greater than {w3-1}, at height {applicant.heightFt}' {applicant.heightIn}''"
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review_reasons.append(weight_reason)
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applicant_review_reasons.append(weight_reason)
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elif applicant.weight >= w4:
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is_dtq = True
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reason = "Declined due to high BMI of one or more applicants"
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reason = f"Applicant weight {applicant.weight}lbs is greater than {w4-1}, at height {applicant.heightFt}' {applicant.heightIn}''"
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dtq_reasons.append(reason)
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applicant_dtq_reasons.append(reason)
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rx_spend_applicant, rx_review_reasons = await self.calculate_rx_spend(phq, applicant_id)
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if rx_review_reasons:
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@ -494,17 +507,26 @@ class EstimationService:
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rx_spend += rx_spend_applicant
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applicant_new_tier = self.get_tier(plan_coverage, rx_spend_applicant)
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applicant_new_tier, tier_reason = self.get_tier(plan_coverage, rx_spend_applicant)
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if applicant_new_tier is None:
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is_dtq = True
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reason = "Declined due to high Rx spend"
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dtq_reasons.append(reason)
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dtq_reasons.append(tier_reason)
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applicant_dtq_reasons.append(tier_reason)
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if applicant_new_tier and applicant_new_tier > applicant_tier:
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applicant_tier = applicant_new_tier
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reason = f"Rx spend increased tier to {applicant_new_tier}."
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accept_reasons.append(reason)
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applicant_accept_reasons.append(reason)
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if applicant_dtq_reasons:
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final_reason = "\n".join(applicant_dtq_reasons)
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elif applicant_review_reasons:
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final_reason = "\n".join(applicant_review_reasons)
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elif applicant_accept_reasons:
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final_reason = "\n".join(applicant_accept_reasons)
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else:
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final_reason = f"Tier {applicant_tier.value} assigned with Rx spend within allowed limits."
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estimation_results.append(
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EstimationResult(
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name=applicant.firstName,
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@ -513,7 +535,7 @@ class EstimationService:
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bmi=self.calculate_bmi(applicant.weight, applicant.heightFt, applicant.heightIn),
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tier=applicant_tier.value,
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rx_spend=rx_spend_applicant,
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message=reason if reason else f"Tier {applicant_tier.value} assigned with Rx spend within allowed limits."
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message=final_reason,
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)
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)
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@ -543,14 +565,16 @@ class EstimationService:
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results=estimation_results
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)
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new_tier = self.get_tier(plan_coverage, rx_spend)
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new_tier, tier_reason = self.get_tier(plan_coverage, rx_spend)
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if new_tier is None:
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dtq_reasons.append(tier_reason)
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reason = "\n".join(dtq_reasons)
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return EstimationResponse(
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status="rejected",
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details=EstimationDetails(
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dtq=True,
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reason="Declined due to high Rx spend",
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reason=reason,
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price_id=plan_price_id,
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),
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results=estimation_results
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@ -561,15 +585,26 @@ class EstimationService:
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plan_price_id = self.get_plan_price(plans[0], base_tier, plan_coverage)
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status = "accepted" if base_tier is not None else "rejected"
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return EstimationResponse(
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status=status,
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details=EstimationDetails(
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dtq=is_dtq,
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reason=reason,
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price_id=plan_price_id,
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),
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results=estimation_results
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)
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if base_tier is not None:
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reason = "\n".join(accept_reasons)
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return EstimationResponse(
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status="accepted",
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details=EstimationDetails(
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dtq=is_dtq,
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reason=reason,
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price_id=plan_price_id,
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),
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results=estimation_results
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)
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else:
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reason = "\n".join(dtq_reasons)
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return EstimationResponse(
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status="rejected",
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details=EstimationDetails(
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dtq=is_dtq,
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reason=reason,
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price_id=plan_price_id,
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),
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results=estimation_results
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)
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