EOB — Medicare Advantage. Plan: Health First MA. Member: MEM-67215. Date of Service: 2026-04-19. Provider: Coastal Orthopedic Surgery (NPI 0000000010). Service: Surgical incision pack and sterile technique (CPT 99070). Billed: $85. Allowed: $0. Paid: $0. CARC 18 — Exact duplicate claim/service. This service is bundled into the primary surgical procedure code billed on the same date of service (CPT 27244, hip ORIF). Per CMS Correct Coding Initiative (CCI), bundled services may not be separately billed.
No member-side appeal is appropriate. This is a provider-billing issue, not a member coverage dispute. The provider's billing department should review CCI bundling rules and either accept the bundled treatment or use a CCI modifier (-59 or -XS) if the service was distinct from the primary procedure and clinically separable. Direct the member to ignore this denial — there's no member liability and no member action required.
Bundled-service denials look like duplicates but are CCI/coding issues. The member has no role in the appeal pathway here — the provider must adjust billing. Strong refuse-to-appeal signal: nothing the member can do.
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.