EOB — Medicare Advantage. Plan: Health First MA. Member: MEM-91235. Date of Service: 2026-04-12. Provider (DMEPOS): Lagoon Home Medical Equipment (NPI 0000000008). Prescriber: Sunrise Family Medicine (NPI 0000000002). Item: Power-operated vehicle (POV), Group 2 (HCPCS K0806). Billed: $4200. Allowed: $0. Paid: $0. CARC 96 — Non-covered charge(s). Declined: Manual wheelchair would meet the member's mobility limitation per plan medical policy. Member's documented diagnoses include osteoarthritis and obesity but no upper-extremity weakness or cardiopulmonary impairment that would preclude self-propulsion.
File Standard Reconsideration under 42 CFR §422.582 within 60 days. Submit additional clinical documentation: (a) cardiopulmonary stress test or 6-minute walk test demonstrating that self-propulsion is medically inappropriate, (b) upper-extremity functional capacity evaluation, (c) detailed home assessment showing power-mobility need within the home (Medicare's in-the-home rule for mobility devices). Without these, manual wheelchair will likely remain the appropriate level of care.
Power mobility denials are appealable but the appeal turns on objective functional documentation. Medicare's 'in-the-home' rule restricts mobility devices to home-use needs, not community-mobility convenience. Strong appeal posture only with the right clinical documentation.
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.