skills/rationale-drift-review/references/rationale-ledger.md

# Rationale ledger method

## Unit of analysis

Use one row for each proposition that could change the evidence or argument required. Examples:

- the service was not medically necessary;
- conservative care was not documented for the required period;
- the wound measurement did not support the billed amount;
- the record lacked a valid order or signature;
- the product or units could not be reconciled;
- a code, diagnosis pointer, or site was outside program scope.

## Change labels

- `Continued`: same material proposition and claim population.
- `Narrowed`: later decision reduces the scope.
- `Expanded`: same theory reaches more claims, criteria, or evidence.
- `New`: materially different theory requiring a different response.
- `Not repeated`: an earlier rationale is absent from the later decision; its disposition remains unresolved unless the decision or governing procedure establishes otherwise.
- `Expressly withdrawn or resolved`: the later decision affirmatively rejects, withdraws, or resolves the earlier rationale for the relevant claims; cite that language. Do not infer waiver or finality beyond what it supports.
- `Contradictory`: propositions cannot reasonably both be true on the stated record.
- `Unclear`: decision language is too vague for confident classification.

## Avoid false drift

Check whether the apparent change results from:

- different claims, dates, wounds, products, or record sets;
- new evidence submitted at the later stage;
- the same rule explained with greater specificity;
- correction of an obvious clerical error; or
- a decision addressing only one preserved issue.

## Procedural significance

Describe the practical consequence before making an advocacy claim. Useful questions include:

- Could the appellant reasonably have addressed the later theory earlier?
- Did the decision identify why the earlier theory changed?
- Did the later reviewer acknowledge newly submitted evidence?
- Were related claims separated in a way that created inconsistent adjudication?
- What relief would cure the problem: clarification, remand, reopening, claim-specific reconsideration, or full merits review?

## Sources

- Arclight, Rationale Drift in Medicare Audit Appeals: https://www.arclightaction.com/insights/rationale-drift-medicare-audit-appeals
- Arclight, Due Process Denied: https://www.arclightaction.com/insights/due-process-denied
- CMS fee-for-service appeals: https://www.cms.gov/medicare/appeals-grievances/fee-for-service