EOB — Medicare Advantage. Plan: Health First MA. Member: MEM-84102. Date of Service: 2026-03-25 to 2026-04-22. Provider: Magnolia Skilled Nursing Facility (NPI 0000000007). Service: SNF days 30-58 of post-stroke rehabilitation stay. Billed: $11200 (28 days @ $400/day). Allowed: $0. Paid: $0. CARC 119 — Benefit maximum for this time period or occurrence has been reached. UM determination: Patient has plateaued in functional gains; further skilled rehabilitation does not meet the daily-skilled-care criterion required for continued SNF benefit.
Initiate fast-track appeal to the IRE (Independent Review Entity) under 42 CFR §422.626 BEFORE the discharge or termination of skilled benefit takes effect. The plan must continue paying for skilled care during the appeal. Submit therapy notes documenting any continued measurable functional gains, even small ones — the 'plateau' standard requires NO progress, not just slowed progress. Recommend therapy team document goal modifications rather than goal abandonment.
SNF skilled-vs-custodial denials have a fast-track appeal pathway specific to MA plans (§422.626). The IRE pathway is the strongest mechanic available — different from standard reconsideration — and benefits continue during appeal. The 'plateau' standard is also commonly misapplied; documented small gains rebut it.
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.