EOB — Medicare Advantage. Plan: Health First MA. Member: MEM-32180. Date of Service: 2026-04-05. Provider: Cocoa Beach Hospital (NPI 0000000006). Surgeon: Coastal Orthopedic Surgery (NPI 0000000010). Service: Emergent open reduction and internal fixation, hip fracture (CPT 27244). Billed: $14200. Allowed: $0. Paid: $0. CARC 197 — Precertification/authorization/notification/pre-treatment absent. Declined for absence of prior authorization. Member was admitted via Emergency Department after a fall.
File expedited reconsideration under 42 CFR §422.584 immediately. Emergency services are exempt from prior authorization requirements under MA plan rules and 42 CFR §422.113 — the denial is procedurally improper. Request that the plan reprocess the claim citing the ED admission as the originating event and the inpatient surgery as treatment of the emergent condition. Member should not be balance-billed during the appeal.
PA-absent denials for genuinely emergent care are improperly denied — emergency services bypass PA. The appeal should cite §422.113 (emergency services coverage) directly rather than treating this as a routine PA-retroactive request. Strong appeal posture; member should not be left with the bill.
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.