EOB — Medicare Advantage Part B. Plan: Health First MA-PD. Member: MEM-50912. Date of Service: 2026-04-19. Provider (infusion): Riverside Specialty Pharmacy (NPI 0000000009). Prescriber: Brevard Cardiology Associates Rheumatology Division (NPI 0000000003). Medication: Adalimumab biosimilar 40mg, monthly (HCPCS J0135). Billed: $1900. Allowed: $0. Paid: $0. CARC 22 — This care may be covered by another payer per coordination of benefits. RARC N435 — Exceeds number/frequency approved/allowed within time period without support documentation. Step therapy policy requires documented 12-week trial of methotrexate before biologic therapy.
File coverage determination request with the plan citing one of the Part B step-therapy override criteria: (a) documented intolerance to methotrexate (liver toxicity, intractable nausea, alopecia), (b) contraindication (pregnancy, severe renal impairment, active liver disease), (c) prior trial failure documented in medical records, or (d) clinical instability requiring rapid disease control. If override criteria apply, request expedited determination under §422.572 — 72-hour decision. If denied, escalate to Standard Reconsideration §422.582.
Step-therapy denials for biologics are appealable through the coverage-determination override pathway. The RARC N435 + CARC 22 combo is the standard step-therapy signal. Strong appeal posture if any of the four override criteria are documented; weak posture without them.
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.