EOB — Medicare Advantage. Plan: Health First MA. Member: MEM-08471. Date of Service: 2026-04-18. Provider: Coastal Orthopedic Surgery (NPI 0000000010). Facility: Cocoa Beach Hospital (NPI 0000000006). Service: Shoulder arthroscopy with rotator cuff repair (CPT 29827). Billed: $8420 (surgeon) + $4310 (facility). Allowed: $0. Paid: $0. CARC 197 — Precertification/authorization/notification/pre-treatment absent. This service requires prior authorization. No authorization on file at the time of service.
Request retroactive coverage determination under 42 CFR §422.566. Member should contact Member Services within 60 days; surgeon's office should submit clinical records demonstrating the procedure met the plan's medical-necessity criteria for outpatient rotator cuff repair. If retroactive determination is denied, file Standard Reconsideration under §422.582.
Prior-auth-absent denials are appealable but the path is slightly different from medical-necessity denials — the first step is a retroactive coverage determination request (organization determination), not directly a reconsideration. If the org determination denies, THEN reconsideration follows. Member rights survive the procedural gap.
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.