Durable medical equipment denials are among the most overturned on appeal. This template addresses the most common denial reasons: lack of medical necessity, documentation gaps, and ABN issues.
TODAY'S DATE
PAYER NAME
DME Appeals Department
PAYER ADDRESS / FAX
RE: Appeal of DME/DMEPOS Claim Denial
Patient: PATIENT FULL NAME
Member ID: MEMBER ID
Date of Birth: MM/DD/YYYY
Claim Number: CLAIM NUMBER
Date of Service: DATE
Equipment: EQUIPMENT DESCRIPTION
HCPCS Code: HCPCS CODE — e.g., E1390 for oxygen concentrator
Denial Code: DENIAL / REMARK CODE
Dear DME Appeals Review Department,
We are writing to appeal the denial of the above-referenced claim for durable medical equipment. The equipment was prescribed by PRESCRIBING PROVIDER NAME, CREDENTIALS on PRESCRIPTION DATE for the treatment of DIAGNOSIS — ICD-10 CODE AND DESCRIPTION.
Basis for Appeal:
The denial was issued with reason: "DENIAL REASON FROM EOB." We respectfully contend that this determination was made in error for the following reasons:
1. Medical Necessity is Established:
The patient's condition — DIAGNOSIS — requires EQUIPMENT to CLINICAL PURPOSE, e.g., "maintain adequate oxygen saturation levels" / "support mobility and prevent falls". The prescribing physician documents that CLINICAL NARRATIVE: key findings, test results, prior treatment history. This meets the payer's criteria for coverage under POLICY NAME OR LCD NUMBER — search Axlow for the exact citation.
2. Documentation is Complete:
Enclosed is the complete documentation package including: a signed physician order, INCLUDE IF APPLICABLE: Certificate of Medical Necessity (CMN), clinical notes from the face-to-face encounter on DATE, and all supporting diagnostic results. All requirements under PAYER NAME's DME coverage policy have been satisfied.
IF PRIOR AUTH WAS OBTAINED: Prior authorization was received on [DATE], authorization number [AUTH#]. A copy is enclosed.
Enclosures:
We request that this claim be reconsidered and reprocessed for payment. Please contact our office at PHONE with any questions.
Sincerely,
AUTHORIZED SIGNATORY NAME
TITLE
PROVIDER / SUPPLIER NAME
NPI: NPI | Tax ID: TAX ID
Axlow indexes UHC, Humana, Aetna, Medicare, and more — search the exact LCD or coverage policy that applies to your equipment, and paste the cite directly into your appeal.