Medicare DME Claim Denied: How to Appeal

Durable medical equipment (DME) — wheelchairs, hospital beds, oxygen equipment, CPAP machines, walkers, and similar items — is covered under Medicare Part B when it meets specific criteria. DME denials are common, often due to documentation gaps rather than genuine lack of medical necessity. Knowing the rules puts you in a much stronger position to appeal.

What Medicare DME Covers

Medicare Part B covers durable medical equipment that is:

• Medically necessary for use in the home
• Durable (expected to last at least 3 years)
• Ordered by a physician enrolled in Medicare
• Supplied by an accredited, Medicare-enrolled DMEPOS supplier

Common covered items include: wheelchairs and scooters, hospital beds, oxygen equipment, CPAP/BiPAP devices, walkers and crutches, blood glucose monitors, nebulizers, and certain prosthetics and orthotics.

The Face-to-Face Examination Requirement

Before Medicare covers certain DME items — particularly power wheelchairs and other complex rehab technology — the ordering physician must conduct a face-to-face examination of the patient within a specific timeframe (typically 6 months before the order). The examination must be documented in the medical record and must support the medical necessity of the equipment.

If your DME claim was denied because the face-to-face requirement was not met or not documented, this is a correctable error. Work with your physician to ensure the clinical notes from your examination are included in the appeal.

Certificate of Medical Necessity (CMN)

Many DME items require a Certificate of Medical Necessity (CMN) — a standardized form completed by the prescribing physician that documents why the equipment is medically necessary. The CMN must be completed accurately and completely.

Common CMN-related denial reasons:

• CMN not submitted with the claim
• CMN completed incorrectly or missing required information
• CMN not signed by the ordering physician
• CMN does not support the specific item billed

Review the CMN that was submitted. If it contains errors or omissions, an amended CMN and a corrected claim submission may resolve the denial without a full appeal.

DMEPOS Competitive Bidding: Use an Approved Supplier

Medicare has implemented a competitive bidding program for certain DME in specific geographic areas. Under this program, Medicare only covers items from contract suppliers in those areas. If your DME was provided by a non-contract supplier in a competitive bidding area, Medicare may deny the claim.

Before purchasing DME, verify that the supplier is both:

1. Medicare-enrolled and accredited (check at medicare.gov/care-compare)
2. A contract supplier if you are in a competitive bidding area

If you were not informed that your supplier was not a contract supplier, you may have grounds to appeal based on good faith reliance.

The 5-Level DME Appeal Process

Level 1 — Redetermination by the MAC File within 120 days of the denial notice. Include all missing documentation (CMN, face-to-face notes, medical records supporting necessity). Many DME denials are overturned at redetermination when proper documentation is provided.

Level 2 — Reconsideration by the QIC File within 60 days of the MAC's redetermination decision. The QIC is an independent reviewer not affiliated with your MAC.

Level 3 — ALJ Hearing at OMHA File within 60 days if the amount in controversy meets the threshold (approximately $180 in 2025).

Level 4 — Medicare Appeals Council File within 60 days of the ALJ decision.

Level 5 — Federal District Court Available for qualifying cases after MAC review.

Building a Strong DME Appeal

Your appeal package should include:

• The physician's detailed clinical notes from the face-to-face examination
• A corrected or amended CMN if the original was incomplete
• Medical records establishing the diagnosis and functional limitations
• Documentation of why alternative lower-cost equipment is inadequate for your specific needs
• For power wheelchairs: documentation that you cannot propel a manual wheelchair
• The supplier's invoice and Medicare Supplier Standards compliance documentation

Coverage Policies to Reference

Medicare covers DME based on Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs) issued by CMS. Look up the relevant LCD for your specific equipment on the CMS website (cms.gov/medicare-coverage-database). Your appeal should demonstrate that your situation meets the specific coverage criteria outlined in the applicable LCD.

Get Free Help

SHIP counselors (shiphelp.org) can help you navigate DME appeals. For complex DME disputes, particularly involving power wheelchairs or complex rehab technology, consider consulting with a Medicare beneficiary advocacy organization or a patient advocate.

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Related Reading:

• How to Write an Insurance Appeal Letter
• What Is Medical Necessity?
• Internal vs External Insurance Appeal