Episodic test-time adaptation resets a frozen segmenter to source weights $M_0$ on each case and adapts for a fixed step count. A fixed horizon conflates a cohort-level question, how far to adapt, with an irreducibly per-case one, whether this case should be adapted at all.

Cohort means hide that decision: on cross-vendor cardiac MRI the mean $Δ$Dice from adaptation is statistically indistinguishable from zero while 58.7% of cases are individually made worse. We quantify this harm as harmful accepted area (HA), the harmful fraction of the edited area a controller deploys.

Held-out tuning gives a stronger baseline than a fixed horizon, but the budget it selects transfers on neither of the two main medical benchmarks, and no global budget can condition on the case. We show that prediction fragmentation---the disagreement geometry between $M_0$ and the adapted mask $M_k$---predicts HA with no labels or extra backward passes at decision time, comparably on three benchmarks (Spearman $ρ$ 0.50--0.60), at a quarter of gradient-norm's latency.

A case-level router built on it cuts HA from 0.228 to 0.139 on a benchmark that took no part in its design, with the design frozen and only cut-points recalibrated there. On the cardiac benchmark the design was selected on, the router cuts HA from 0.129 to 0.013 at matched Dice and 1.10 deployed updates, against the retrospective-best budget found post hoc on evaluation labels, and reduces that 58.7% to 20.0%, an upper bound we quantify.

Where the retained cases are not net-helped (as on prostate), the router still cuts HA but concedes accuracy, a boundary we report. Thresholds are fit once on a labeled split disjoint from evaluation; decisions use no labels or gradients.

The template ports across architecture and domain (nnU-Net$\to$SegFormer, Cityscapes$\to$ACDC) with coordinate, thresholds and per-bucket actions instantiated per domain.