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18 decisions · 17 governed
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MS
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Query clinical evidence, member history, plan benefits, guidelines, or any care question
What is the medical necessity basis for extending cardiac rehabilitation for Member M-8832 beyond the standard 36-session benefit?
09:30 AM
MS
Enterprise Brain Answered in 4.1s · 8 sources consulted
Member Profile
Member M-8832 (DOB: 15 Mar 1958, Age: 68). Underwent CABG surgery 12 March 2026. Enrolled in Phase II/III cardiac rehabilitation since 15 April 2026.
Current Clinical Status
Measure Value Target Status
Sessions completed36 of 36Standard benefit exhausted
Functional capacity5.2 METs7.0 METs
Ejection fraction42%55%+
HbA1c7.8%<7.0%
BMI32.1<30
Medical Necessity Basis
ACC/AHA 2026 Guidelines recommend continuation when functional capacity below target after standard program
Member has not achieved target METs — incomplete physiological recovery
Comorbidity burden (diabetes, obesity) associated with longer recovery per AACVPR risk stratification
Dr. Robert Kim documents continued improvement: 3.1 METs at session 12 → 5.2 METs at session 36
Recommendation
12-session extension (sessions 37–48) is clinically supported. Re-assessment at session 48.
Plan Benefit Reference
Standard: 36 sessions per cardiac event (Section 4.2.3)
Extension: up to 24 additional sessions with medical necessity + clinical review (Section 4.2.3.b)
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Governance

Domain concepts resolved:
Medical necessity → plan definition Section 1.4 cross-referenced with ACC/AHA clinical criteria
Standard benefit → 36 sessions per cardiac event per Plan Document 4.2.3
Extension provision → Section 4.2.3.b, up to 24 additional with documented medical necessity
Functional capacity target → 7.0 METs for age 68, post-CABG per ACC/AHA Table 7.2
Semantic model v3.4.1
4 concepts resolved · model v3.4.1
1Parsed query & intent
2Resolved member — M-8832
3Retrieved 8 sources across 5 systems
4Evaluated clinical status vs ACC/AHA targets
5Checked plan benefit & extension provisions
6Assessed medical necessity criteria
7Composed governed answer
Care management platform — cardiac rehab session log (2)
EHR — CABG operative & cardiology notes (2)
Clinical guideline library — ACC/AHA & AACVPR (2)
Plan benefit configuration — cardiac rehab benefit (1)
Lab system — HbA1c & biometrics (1)
EB-2026-0809-HP-02341
Immutable decision log · SHA-256 anchored
Recorded 09 Aug 2026 · 09:30 AM