Durable Medical Equipment Appeal Letter Template

When to Use This Template

Use this letter for denials of:

• Wheelchairs (manual or power)
• CPAP/BiPAP machines
• Prosthetic limbs
• Hospital beds
• Oxygen equipment
• Orthotic devices
• Diabetic supplies

Template

[Your Name] [Your Address] [Date] [Insurance Company] Appeals Department [Address] Re: DME Appeal — [Equipment Type] Claim Number: [Number] Member ID: [Your ID] Patient: [Name] | DOB: [Date]

Dear Appeals Review Committee,

I am appealing the denial of [specific equipment] (HCPCS Code: [code]) denied on [date] under claim number [number]. The stated reason for denial was [denial reason].

Medical Necessity:

[Patient name] has been diagnosed with [diagnosis/ICD-10 code] which results in [specific functional limitations]. [Treating physician] has determined that [specific equipment] is medically necessary to [restore/maintain function, prevent decline, ensure safety].

Functional Limitations:

Without this equipment, [patient name] is unable to:

• [Specific ADL limitation 1]
• [Specific ADL limitation 2]
• [Specific mobility limitation]
• [Safety concern — falls, inability to use current equipment]

Clinical Documentation:

Enclosed please find:

1. Physician order for [equipment], including diagnosis, medical necessity, and equipment specifications
2. Face-to-face examination notes dated [date] (within 6 months per CMS requirements)
3. Functional assessment documenting mobility/ADL limitations
4. [Physical/occupational therapist evaluation if applicable]
5. Prior equipment failure documentation [if replacing existing equipment]

Requested Action:

Please approve [specific equipment] as medically necessary for [patient's] functional needs. I am available to provide additional documentation if needed.

Sincerely, [Your Name]

DME-Specific Tips

• Face-to-face encounter documentation is critical for Medicare DME appeals
• HCPCS codes must match the exact equipment prescribed
• Power mobility devices require a detailed mobility exam