EOB — Medicare Advantage. Plan: Health First MA. Member: MEM-26571. Date of Service: 2026-04-01 to 2026-04-30 (rental month 4). Provider (DMEPOS): Lagoon Home Medical Equipment (NPI 0000000008). Item: CPAP rental month 4, including disposable supplies (HCPCS E0601 + A7034). Billed: $185. Allowed: $0. Paid: $0. CARC 96 — Non-covered charge(s). RARC M16 — Alert: Please see our website, mailings, or bulletins for more details concerning this policy/procedure/decision. Usage data: 14 nights of usage during 30-day window (≥4 hours per night). Plan policy requires ≥21 nights ≥4 hours/night to continue rental.
Appeal under 42 CFR §422.582 if member has documented medical reasons for the gap (illness, hospitalization, mask-fit issues being addressed). Coordinate with the DME provider for a re-fit appointment if mask discomfort is the issue. If non-compliance is genuine and unexplained, recommend the member resume nightly use for 90 days and request a fresh adherence-evaluation period rather than appealing the historical denial.
DME compliance denials are technically appealable but often unsuccessful when there's no clinical reason for the gap. The CSR's most useful action is often coordinating mask-fit support and a fresh adherence period rather than fighting the historical denial.
Per-scenario model output is captured during a leaderboard Run all. Trigger a run from the leaderboard to see each variant’s output side-by-side with the ground truth here.
To run this scenario through the live cockpit, copy the EOB above into the cockpit and watch the streamed triage in context.