Common reasons for DME coverage denial

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Common reasons for DME coverage denials

This section explains the most common reasons a claim is denied and what steps you can take next.

Denials for durable medical equipment (DME) are common.

A health insurance denial is when your insurance company says they will not cover, or pay for, a medical service, treatment, or prescription. This means you may have to pay the full cost. A denial does not always mean your request was wrong or that you can’t get coverage.

A denial may happen because the DME is considered not medically necessary, or not covered under your health insurance plan policy. However, many denials also happen because of missing information, coding errors, or paperwork issues. Most of the time, these problems can be fixed through the appealing the decision.¹

You have the right to understand why a claim was denied, and to appeal the decision. Your DME provider can help you submit an appeal on your behalf.¹

Learn how to file an appeal with Medicare.¹

Medicare related reasons for coverage denials

Reasons include:

Signature Requirements

Medicare requires appropriate signatures in medical records and on the Standard Written Order.

If signatures are missing or incomplete, the claim may be denied.² The claim may also be denied if the signatures do not meet Medicare’s signature requirements.²

Learn how to comply with Medicare signature requirements³

Medicare Program Integrity Manual (Chapter 3, Section 3.3.2.4) for more details²

Incomplete Chart Notes

Your healthcare provider’s chart notes must clearly describe your condition and your need for the equipment^.4

Insufficient Medical Necessity Documentation

A Letter of Medical Necessity must clearly explain why the equipment is medically necessary for your condition.⁵

If the explanation is missing or not clear, the claim may be denied.^4,5

Learn more about medical neccessity⁵

Outdated Chart Notes

If the chart notes are outdated or do not include enough detail, coverage may be denied.^2,4

Incorrect Diagnosis Codes

Your claim must include the correct medical diagnosis code.

ICD-10 codes are used by healthcare providers to classify diagnoses and symptoms for insurance claims.²

If the wrong diagnosis code is submitted, the claim may be denied.

Wrong Equipment Codes

Medical equipment must also be billed using the correct equipment code.

CPT and HCPCS codes are used to bill for medical services and equipment.²

If the wrong code is used, the claim may not process correctly.

DME provider related reasons for coverage denials

Reasons include:

Your claim might be denied because your DME supplier is out-of-network.

This is common. It does not necessarily mean you must change suppliers.

You may be able to appeal and ask your plan to treat the out‑of‑network supplier as in‑network. ⁶

Your insurer may make an exception if:

No in-network supplier is available within a reasonable time, distance, or specialty.⁶
The situation involves an emergency.⁶
You need continuity of care, and changing suppliers could disrupt treatment.⁶
Generally, you may need continuity of care if you are undergoing active treatment for a serious or complex condition.

In some situations, your plan may pay out‑of‑network services at in‑network rates.⁶

For example, your plan may pay in-network rates when access‑to‑care standards aren’t met.⁶

References

Medicare. Filing an Appeal. Available at: https://www.medicare.gov/providers-services/claims-appeals-complaint. AccessedJanuary 22, 2025.
Centers for Medicare & Medicaid Services. Medicare Program Integrity Manual, Chapter 3: Verifying Potential Errors and Taking Corrective Actions. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdf. Accessed January 22, 2025.
Centers for Medicare & Medicaid Services. Complying with Medicare Signature Requirements. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdf. Accessed January 22, 2025.

How to be your own best advocate

This guide shows you how to be a strong advocate for yourself by working closely with your health care team and asking clear questions.

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Guide to understanding your insurance coverage

When you know how to read your insurance paperwork, you can make informed decisions and be a stronger advocate for yourself.

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Reasons for DME coverage denial

When your healthcare insurance provider denies coverage for a medical device, this means they will not approve or pay for the device.

Learn more

Stakeholder engagement

There are many different people who can help you get the medical device you need approved.

Learn more

Letters of medical necessity

A Letter of Medical Necessity can help explain why you need a specific device.

Learn more

Glossary

This glossary includes clear definitions to help you better understand your coverage and the approval process.

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