Durable medical equipment (DME) denials — covering wheelchairs, walkers, CPAP machines, prosthetic limbs, glucose monitors, hospital beds, and other equipment — are extremely common. These appeals can be among the most important: the right equipment is often essential to a patient's ability to function and maintain independence. Here's how to fight DME denials effectively.
What Counts as Durable Medical Equipment?
Under the Medicare definition (42 CFR §414.202), durable medical equipment is equipment that: (1) can withstand repeated use; (2) is primarily and customarily used for medical purposes; (3) is generally not useful to a person in the absence of illness or injury; and (4) is appropriate for use in the home. Most private insurance plans use the same or similar definition.
Common DME items subject to coverage disputes include: power wheelchairs and mobility scooters; CPAP/BiPAP machines for sleep apnea; prosthetic limbs and orthotics; hospital beds and adjustable mattresses; insulin pumps; infusion pumps; oxygen equipment; and walkers and crutches.
The Certificate of Medical Necessity (CMN)
For most DME, the treating physician must complete a Certificate of Medical Necessity (CMN) — a standardized form documenting the clinical need for the equipment. The CMN is different from a general Letter of Medical Necessity and must typically be completed on Medicare's specific CMN forms or the insurer's own forms. Errors or incomplete CMNs are a common cause of DME denials. Have the physician review and complete the CMN carefully, ensuring all fields are filled and the diagnosis codes match the equipment requested.
Common DME Denial Reasons
- Not medically necessary: Most common reason — counter with detailed physician documentation and relevant functional assessments
- Insufficient documentation: CMN incomplete, missing diagnosis codes, or inadequate clinical justification
- Not the least costly alternative: Insurer claims a less expensive item would meet the clinical need — counter by documenting why the requested item's specific features are medically required
- Beneficiary doesn't qualify: Doesn't meet specific clinical criteria (e.g., mobility criteria for power wheelchairs)
- Same/similar equipment: Already received same or similar equipment within the replacement period
Power Wheelchair Appeals
Power wheelchair appeals are among the most contested DME disputes. Medicare requires that the beneficiary have a mobility limitation that significantly impairs their ability to participate in mobility-related activities of daily living (MRADLs) and that they cannot safely self-propel a manual wheelchair. The required documentation includes: a face-to-face examination by the treating physician; a detailed written order; documentation that the patient can safely operate the device; and for complex rehabilitative power wheelchairs, often an assessment by a physical or occupational therapist.
CPAP Machine Appeals
CPAP machine denials often involve: insufficient documentation of sleep apnea diagnosis (must typically have a sleep study); failure to meet severity criteria (AHI score thresholds); or issues with the supplier's documentation. For Medicare, CPAP is covered for patients with obstructive sleep apnea with an AHI of 15+ per hour, or AHI 5-14 with symptoms. Commercial plans often follow similar criteria. Ensure the sleep study documentation is complete and shows the patient meets the criteria.
ACA Essential Health Benefits
Under ACA §1302(b)(1)(F) and 42 U.S.C. §18022, habilitative and rehabilitative services and devices are essential health benefits that ACA Marketplace plans must cover. This explicitly includes many types of DME. If your plan is denying DME that constitutes habilitative or rehabilitative devices, this may violate the ACA's essential health benefit requirements.
Medicare DME Supplier Requirements
For Medicare coverage, DME must be obtained from a Medicare-enrolled supplier. Using a non-enrolled supplier is a common reason for Medicare DME denial that has nothing to do with medical necessity. Always verify that your DME supplier is Medicare-enrolled before ordering. If you received DME from a non-enrolled supplier, the solution is to get the same equipment from an enrolled supplier, not to appeal on medical necessity grounds.