Medicare Denied Your DME — Appeal Guide & Checklist

What This Means

A durable medical equipment (DME) denial almost always turns on one of Medicare’s three conditions of payment: a standard written order from your treating practitioner, a face-to-face visit within the 6 months before that order for items on CMS’s required list (power wheelchairs and scooters, hospital beds, oxygen equipment, and many braces), and medical records that show the item meets Medicare’s coverage test (42 CFR 410.38). Act now: call the supplier and ask exactly which requirement the denial cites, then have your doctor’s office send the missing order, visit note, or records with your appeal — within 120 days of receiving your Medicare Summary Notice (MSN) for Original Medicare (receipt is presumed 5 days after the date on it, 42 CFR 405.942(a)) or 65 days from the date on your denial notice for Medicare Advantage.

If a Medicare Advantage plan refused prior authorization before the equipment was delivered, you appeal to the plan first and it must decide within 30 calendar days; an appeal about payment for equipment you already have gets 60 calendar days (42 CFR 422.590).

Not sure this is your situation?

• The supplier had you sign a notice before delivery and is now billing you — see Advance Beneficiary Notice (ABN).
• The supplier turned out not to be enrolled in Medicare at all — see provider not enrolled.
• Your Medicare Advantage plan denied a prior authorization request — see prior authorization denied.

Medicare Part B covers equipment that can withstand repeated use, has an expected life of at least 3 years, serves a medical purpose, is generally not useful to someone without an illness or injury, and is appropriate for use in the home (42 CFR 414.202). Medicare’s own list includes canes, walkers, wheelchairs and scooters, hospital beds, CPAP therapy, oxygen equipment, infusion pumps, and blood sugar monitors and test strips (Medicare.gov). After the $283 2026 Part B deductible you pay 20% of the Medicare-approved amount if the supplier accepts assignment (Medicare.gov costs). Most equipment is rented: Medicare pays a monthly rental for up to 13 continuous months, after which the supplier must transfer ownership to you (42 CFR 414.229); oxygen equipment rents for up to 36 months (42 CFR 414.226).

On your MSN or plan notice the denial usually carries one of these X12 reason codes: CO-50, “these are non-covered services because this is not deemed a ‘medical necessity’ by the payer”; CO-16, “claim/service lacks information or has submission/billing error(s)” (the remark code beside it names the missing item); CO-197, “precertification/authorization/notification/pre-treatment absent”; CO-B7, “this provider was not certified/eligible to be paid for this procedure/service on this date of service”; and, mostly from Medicare Advantage plans, CO-204, “this service/equipment/drug is not covered under the patient’s current benefit plan.” A denial usually means one of Medicare’s requirements wasn’t met — not that you don’t need the equipment.

Why This Happens

• The standard written order was missing or incomplete. Every DMEPOS item needs a written order with six elements — your name or Medicare number, a description of the item, the quantity if applicable, the order date, and the treating practitioner’s name or NPI and signature. For items on CMS’s required list the order must reach the supplier before delivery; for everything else, before the claim is filed (42 CFR 410.38(d)). The old Certificate of Medical Necessity (CMN) no longer exists: CMS discontinued CMNs and DME Information Forms for dates of service on or after January 1, 2023, so the medical record now has to carry the justification those forms used to.
• No face-to-face encounter on file. For power mobility devices and the other items on CMS’s Required Face-to-Face Encounter and Written Order Prior to Delivery List — 83 items today, rising to 105 on October 28, 2026, including power wheelchairs and scooters, hospital beds, oxygen systems and concentrators, and many braces — your treating practitioner (a physician, physician assistant, nurse practitioner, or clinical nurse specialist) must have examined you, in person or by a qualifying telehealth visit, within the 6 months before writing the order, and that visit must be documented and sent to the supplier (42 CFR 410.38(d)(2)). As of this review, CPAP machines are not on that list.
• Prior authorization wasn’t obtained. Original Medicare requires prior authorization only for items on CMS’s Required Prior Authorization List — power mobility devices, certain back, knee, and other orthoses, pressure-reducing support surfaces, certain lower-limb prostheses, and (from April 13, 2026) pneumatic compression devices, with further codes added October 28, 2026. A claim for a listed item that was delivered without an affirmative decision is denied (usually CO-197). Medicare Advantage plans may require prior authorization for a far wider range of equipment; in traditional Medicare only a limited set of services, including DME, is subject to it (KFF, 2024).
• The supplier isn’t enrolled or accredited. Every DMEPOS supplier and each of its locations must meet CMS’s quality standards and be accredited for the specific products it bills in order to enroll and be paid (42 CFR 424.57(c)(22)); Medicare.gov’s advice is to confirm a supplier is enrolled before you get DME (Medicare.gov). These denials usually show CO-B7.
• The equipment wasn’t deemed medically necessary (CO-50). The reviewer decided the records didn’t document a condition that meets the coverage test in 42 CFR 414.202 and the item’s medical policy, or didn’t explain why this particular item — rather than a simpler one — is needed.
• Competitive bidding rules (only for older dates of service). Medicare’s DMEPOS Competitive Bidding Program has been in a temporary gap period since January 1, 2024, after the last contracts (Round 2021, off-the-shelf back and knee braces) expired December 31, 2023. As of this review no contract-supplier requirement is in effect; CMS’s target for the next round (continuous glucose monitors and insulin pumps, urological and ostomy supplies, catheters, and off-the-shelf braces) is no later than January 1, 2028. A “non-contract supplier” denial can only apply to dates of service when contracts were in force.

Should You Appeal?

What To Do Next

1. Read your denial notice carefully. Find the reason code (CO-50, CO-16, CO-197, CO-B7, or CO-204) and any remark code beside it. This tells you exactly what needs to be addressed and whether it is a documentation problem, a supplier problem, or a coverage decision.
2. Contact your doctor’s office. Ask for a copy of the standard written order with all six elements, the note from the face-to-face visit dated within 6 months before the order (for items on the required list), and the clinical records that show why you need this equipment. Many DME denials are resolved simply by supplying this documentation.
3. Contact the DME supplier. Ask whether they are enrolled in Medicare and accredited for this item, whether they accept assignment, and what documentation they had on file when they billed. Medicare.gov’s supplier directory lists enrolled suppliers if you need a different one.
4. File your appeal. For Original Medicare, send a redetermination request with the denial notice, your doctor’s letter of medical necessity, the written order, and the records to the Medicare Administrative Contractor listed on your MSN within 120 days of receiving it (Medicare.gov appeals). For Medicare Advantage, ask the plan for a reconsideration within 65 days of the date on the denial notice; the plan has 30 calendar days to decide a pre-delivery request and 60 calendar days for a payment request (Medicare.gov health plan appeals).
5. Check whether an ABN was provided. Medicare treats you as having known it wouldn’t pay only if you got written notice before the item was furnished (42 CFR 411.404). If the denial was for medical necessity and the supplier gave you no Advance Beneficiary Notice (ABN), the supplier generally bears the cost — not you. But no ABN is required for items Medicare never covers (Medicare.gov), so that protection doesn’t reach statutory exclusions. Contact 1-800-MEDICARE (1-800-633-4227) if you believe you were improperly billed.

Sources

• 42 CFR 410.38 — DMEPOS order, face-to-face encounter, and documentation conditions of payment
• 42 CFR 414.202 — Definition of durable medical equipment
• 42 CFR 414.229 — Capped rental items
• 42 CFR 414.226 — Oxygen and oxygen equipment
• 42 CFR 424.57 — DMEPOS supplier standards and accreditation
• 42 CFR 411.404 — When a beneficiary is considered to have known services were not covered
• 42 CFR 405.942 — Time frame for filing a redetermination request
• 42 CFR 422.590 — Medicare Advantage reconsideration timeframes
• CMS: DMEPOS Order and Face-to-Face Encounter Requirements
• CMS: Prior Authorization Process for Certain DMEPOS Items
• CMS: Discontinuing Certificates of Medical Necessity and DME Information Forms — the January 1, 2023 discontinuation; MLN SE22002 lists the retired forms and states that claims with one attached are rejected and returned
• CMS: DMEPOS Competitive Bidding Program (temporary gap period); next-round timeline and product categories from CMS’s competitive bidding contractor site
• Medicare.gov: Durable medical equipment (DME) coverage
• Medicare.gov: Medicare costs
• Medicare.gov: Your protections (Advance Beneficiary Notice)
• Medicare.gov: Original Medicare appeals
• Medicare.gov: Medicare health plan appeals
• Medicare.gov: Find medical equipment & suppliers
• KFF: Medicare Advantage Prior Authorization and Denial Data, 2024
• X12: Claim Adjustment Reason Codes — official definitions of CO-50, CO-16, CO-197, CO-B7, and CO-204

Frequently Asked Questions