EOB — Medicare Advantage. Plan: Health First MA. Member: MEM-77310. Date of Service: 2026-03-20 to 2026-04-24. Provider: Brevard Cardiology Associates (NPI 0000000003). Service: Cardiac rehabilitation, sessions 37-44 (CPT 93798) × 8. Billed: $1080. 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. The Medicare cardiac rehab benefit covers up to 36 sessions over 36 weeks. Extension to 72 sessions requires documented exceptional circumstances. Documentation submitted did not establish exceptional medical necessity for extension.
File Standard Reconsideration under 42 CFR §422.582 within 60 days, attaching: (1) recent stress test or functional capacity evaluation showing measurable continued progress, (2) documented complications during the initial 36 sessions that delayed standard milestones, (3) clinician attestation that without extension the patient would regress. Note: NCD permits extension to 72 sessions in 36 weeks with prior auth — verify whether prior auth was actually obtained for sessions 37+; if so, the denial may be procedural rather than medical-necessity-based.
Cardiac rehab extension beyond 36 sessions IS permitted under the Medicare benefit (NCD 20.10) but requires exceptional documentation. This is appealable but evidence-dependent — the appeal succeeds when the documentation gap is closed, not when the rule is challenged.
Borderline because the CARC 50 here may be partially procedural — if prior auth for the extension was obtained but not on file, it's actually a Prior Auth Not Obtained scenario (CARC 197). Tests whether the model surfaces this ambiguity in its rationale.
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.