How to Appeal Durable Medical Equipment (DME) Denials

Durable medical equipment — wheelchairs, CPAP machines, prosthetics, hospital beds — is frequently denied due to documentation requirements, preferred supplier mandates, or medical necessity criteria.

What Is DME?

Durable Medical Equipment includes:

  • Wheelchairs and scooters
  • CPAP/BiPAP machines
  • Prosthetic limbs and orthotic devices
  • Hospital beds
  • Oxygen equipment
  • Walkers, crutches, canes
  • Diabetic supplies

Common DME Denial Reasons

  • Medical necessity not documented — physician order lacks required detail
  • Preferred supplier not used — must use plan-designated DME supplier
  • Face-to-face encounter missing — Medicare requires documented exam within 6 months
  • Prior authorization not obtained
  • Wrong code — DME coding is complex; HCPCS code errors are common
  • Rental vs purchase dispute

How to Appeal

  1. Check the physician order — it must include diagnosis, medical necessity, and specific equipment details
  2. Ensure face-to-face documentation — especially for Medicare (required within 6 months of order)
  3. Verify HCPCS codes — incorrect coding is the most common fixable error
  4. Document functional limitations — mobility assessments, ADL limitations, fall history
  5. Include physician letter of necessity — explaining why THIS specific equipment is needed

Medicare DME Appeals

Medicare DME appeals follow the standard 5-level Medicare appeal process. SHIP counselors can assist for free. Medicare requires strict documentation — face-to-face encounter, detailed physician order, and proper medical review.

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Frequently Asked Questions

Does Medicare cover electric wheelchairs?

Medicare covers power wheelchairs when you meet specific mobility criteria and a face-to-face exam confirms the need. The exam must be performed by your treating physician within 6 months. A Certificate of Medical Necessity is also required.

Can I choose my own DME supplier?

For Medicare, you must use a participating DME supplier. For commercial plans, your plan may require a preferred or contracted supplier. Using a non-participating supplier may result in denial or higher costs.

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