EOB — Medicare Advantage HMO. Plan: Health First MA-HMO. Member: MEM-19437. Date of Service: 2026-04-23. Provider: Indian River Endocrinology (NPI 0000000005). Service: Office visit, new patient, level 4 (CPT 99204). Billed: $420. Allowed: $0. Paid: $0. Member liability per claim: $420. CARC 242 — Services not provided by network/primary care providers. Note: At least 3 endocrinologists are in-network within 30 miles of member's home zip code.
Appeal is unlikely to succeed on the merits — HMO plans generally do not cover out-of-network elective care when network alternatives are available. Member may file Standard Reconsideration under §422.582 if there are documented continuity-of-care reasons (existing relationship, specialized expertise unavailable in-network). If no such reasons exist, the cleaner path is to switch to an in-network endocrinologist for future visits. Member retains the right to appeal but should be advised of the low probability of success.
The note about 3 in-network endocrinologists nearby is the key disambiguator. Without continuity-of-care or specialized-expertise grounds, an OON HMO denial for elective care will be upheld on reconsideration. The right CSR triage is HONEST about the appeal's low probability rather than reflexively recommending appeal.
Borderline — technically appealable but the CSR's job is to set member expectations honestly. Tests whether the model couches the appeal recommendation with the right hedge.
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.