EOB — Medicare Advantage Part D. Plan: Health First MA-PD. Member: MEM-71204. Date of Service: 2026-04-22. Provider (pharmacy): Riverside Specialty Pharmacy (NPI 0000000009). Prescriber: Sunrise Family Medicine (NPI 0000000002). Medication: Semaglutide 1mg/0.5mL pen, 30-day supply (Tier 3, Part D non-formulary). Billed: $1080. 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. Note: Indication on prescription is 'weight loss' (Z71.3). Diabetes diagnosis (E11.9) is on the member's problem list but not on this prescription.
Critical disambiguation needed: Medicare Part D does NOT cover GLP-1 agonists for weight loss alone (Z71.3 indication). If prescribed for diabetes (E11.9), the medication is covered subject to step therapy. Recommend prescriber resubmit the prescription with E11.9 as the primary indication if the patient has diabetes; otherwise the denial is correct on the merits and not appealable for the weight-loss indication. If type-2 diabetes is the underlying clinical reason, file coverage determination with E11.9 as primary diagnosis and document failed metformin trial.
This scenario tests the critical Part-D-coverage limitation: weight-loss-only indication is excluded by statute. The CSR's job is to surface this distinction rather than reflexively recommend appeal. Appeals filed for the weight-loss indication will be denied; appeals filed with the diabetes indication and step-therapy-override documentation may succeed.
Borderline — technically classifies as Step Therapy but the statutory exclusion for weight-loss-only is the dominant signal. Tests whether the model surfaces the indication-mismatch issue.
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.