EOB — Medicare Advantage. Plan: Health First MA. Member: MEM-22107. Date of Service: 2026-04-09 to 2026-04-23. Provider: Atlantic Coast Physical Therapy (NPI 0000000001). Service: Aquatic therapy (CPT 97113) × 8 visits. Billed: $960. Allowed: $0. Paid: $0. Denied for medical necessity: CARC 50 — These are non-covered services because this is not deemed a 'medical necessity' by the payer. RARC N115 — This decision was based on a Local Coverage Determination (LCD). The LCD requires aquatic therapy to be performed in a heated therapeutic pool with documented pool-specific functional goals beyond what land-based PT can achieve. Documentation submitted did not establish that distinction.
File a Standard Reconsideration under 42 CFR §422.582 within 60 days. Submit additional clinical documentation establishing why aquatic therapy is medically necessary beyond what land-based PT can achieve — typically pain levels, weight-bearing limitations, range-of-motion targets specific to buoyancy. Request peer-to-peer review with the medical director if initial reconsideration is upheld.
Standard medical-necessity LCD denial. CARC 50 with RARC N115 is the canonical pattern. Appealable per Subpart M; the appeal turns on submitting clinical documentation that addresses the specific LCD criterion the original submission missed. This is exactly the workflow §422.582 contemplates — adverse determination → clinical-evidence-based reconsideration.
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.