EOB — Medicare Advantage. Plan: Health First MA. Member: MEM-49025. Date of Service: 2026-04-08. Provider: Sunrise Family Medicine (NPI 0000000002). Service: Intravenous ferric carboxymaltose 750mg (HCPCS J1439) × 2 doses. Billed: $1280. Allowed: $0. Paid: $0. CARC 197 — Precertification/authorization/notification/pre-treatment absent. IV iron infusions require prior authorization under the plan's specialty drug policy. Prescribing physician's office indicated authorization was requested but the authorization number on the claim does not match plan records.
Confirm whether prior authorization was actually obtained by checking with both the prescribing office and plan medical management. If yes, this is a clerical mismatch — request claim correction with the corrected auth number rather than appeal. If no, request retroactive coverage determination under §422.566 with clinical documentation of failed oral iron therapy or contraindication. Filing window: 60 days from notice.
The auth-number-mismatch detail is the key signal — this may be a billing error rather than a true PA-absent denial. Appropriate triage is to verify the underlying cause before filing a formal reconsideration.
Borderline because the auth-number mismatch suggests a clerical issue. Tests whether the model picks up this nuance vs. defaulting to standard PA-absent appeal flow.
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.