Evidence Explorer

18 decisions · 17 governed
3
MS
Member M-8832
Source System
Document Type
Date Range
Member: M-8832
Trace ID
6 sources found
Clinical Progress Notes — Dr. Robert Kim
EHR SystemLast updated: 28 Jul 2026
Functional assessments, rehabilitation progress, treatment plan
Claims History — Cardiac Rehab Sessions 1–36
Claims SystemLast claim: 1 Aug 2026
Used in 2 traces
Session dates, CPT codes, billed amounts
Functional Capacity Assessment — 28 Jul 2026
EHR SystemRetrieved: 9 Aug 2026, 09:18
Used in 1 trace
METs measurement, ejection fraction, exercise tolerance
ACC/AHA Cardiac Rehabilitation Guidelines 2026
Clinical Knowledge BasePublished: Mar 2026
Used in 2 traces
Extension criteria, comorbidity considerations, functional targets
Plan Document 2026 — Benefits Schedule
Plan AdministrationEffective: 1 Jan 2026
Used in 2 traces
Section 4.2.3 standard benefit, Section 4.2.3.b extension provision
Prior Authorization PA-2026-MH-8832
Authorization SystemApproved: 10 Apr 2026
Used in 1 trace
Original 36-session authorization for cardiac rehab post-CABG

Clinical Progress Notes — Dr. Robert Kim

Valley Heart Associates
Source: EHR System · Last updated: 28 Jul 2026
Used by 2 Brain operations
Progress Note — Cardiac Rehabilitation
M-8832 · 28 Jul 2026
Member M-8832 · 62M · s/p CABG (Apr 2026) · Provider: Dr. Robert Kim, MD
Assessment
62-year-old male enrolled in Phase II cardiac rehabilitation following coronary artery bypass grafting. Has completed the standard 36-session course. Progress is steady but functional recovery remains incomplete relative to age- and procedure-based targets.
Functional capacity: 5.2 METs (target 7.0 METs for age and procedure)
Used in EB-HP-02341, Step 3
Objective Findings
Serial exercise tolerance testing across the rehabilitation course demonstrates a consistent upward trajectory, though the patient has not yet reached the functional target.
Patient demonstrates continued improvement trajectory: 3.1 METs (session 12) → 4.4 METs (session 24) → 5.2 METs (session 36)
Used in EB-HP-02341, Step 3; EB-HP-02356
Plan
Recommend 12-session extension. Comorbidities (T2DM, obesity) are contributing to slower recovery. Patient is motivated and compliant.
Used in EB-HP-02341, Step 4
How This Evidence Connects
Clinical notes validates Medical necessity basis in Claim Adjudication EB-HP-02341
Clinical notes confirms Functional capacity below target reported in Claims History
Clinical notes cross-referenced with ACC/AHA Guidelines Section 7.3 extension criteria
Clinical notes supports Prior Authorization extension request PA-2026-MH-8832-EXT