EOB — Medicare Advantage. Plan: Health First MA. Member: MEM-15822. Date of Service: 2026-04-15. Provider: Palm Bay Imaging Center (NPI 0000000004). Service: MRI lumbar spine without contrast (CPT 72148). Billed: $1850. 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). LCD requires documented 4 weeks of conservative care (PT, NSAIDs, activity modification) prior to advanced imaging for non-radiculopathic low back pain. Member's clinical record shows 2 weeks of conservative care.
Either: (a) file Standard Reconsideration under 42 CFR §422.582 documenting any red-flag findings (radiculopathy, weakness, bowel/bladder dysfunction, trauma) that would override the conservative-care requirement; or (b) complete the additional 2 weeks of conservative care and resubmit. Recommend (a) only if red flags are present in the record; otherwise (b) is the cleaner path.
Conservative-care-timeline LCD denials are appealable but the appeal generally only succeeds when the original submission was incomplete (red flags present but not documented) OR when the patient has documented contraindication to conservative measures. A pure 2-vs-4 week dispute without clinical override usually loses on 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.