How to Win a Denied Equipment (DME) Appeal
A denial is not a no. It is a paperwork problem with a deadline, and families overturn these every day.
The Appeal Path: 6 Steps
First, take a breath: a denial is a paperwork problem, not a verdict on your child
When that letter arrives saying the wheelchair, gait trainer, feeding pump, or communication device your child needs is 'denied,' it can feel like a door slamming. It is not. In the world of durable medical equipment (DME), an initial denial is an ordinary, expected step, and a large share of them get overturned on appeal, especially for children.
Insurers and Medicaid plans process enormous volumes of requests, and denials frequently come down to a missing document, a code that did not match, or a note that did not spell out the word 'why' clearly enough. None of that is a judgment about whether your child deserves the equipment. It is a fixable gap. Your job over the next few weeks is to close that gap with evidence and hit your deadline.
Read this whole page once so you can see the full path. Then come back and take it one step at a time.
Read the denial letter like a treasure map (it tells you exactly how to win)
Everything you need to start is on the denial letter, so read it slowly, twice. Two things matter most. First, the reason for denial: it will be something like 'not medically necessary,' 'insufficient documentation,' 'considered not covered,' or a specific policy or billing code. That reason is your target; your appeal has to answer it directly.
Second, the appeal deadline. This is the single most important number on the page, and it varies by plan and by state, so do not guess it. Commercial plans, Medicaid, and Medicare Advantage each set their own windows, and missing one can force you to start over. Write the deadline on your calendar and set a reminder several days early.
The letter also tells you how to appeal (mail, fax, phone, or an online portal) and often lists your right to a free copy of the exact policy or criteria used to decide. Request that policy. It shows you the checklist you need to satisfy.
The secret weapon: a strong Letter of Medical Necessity
The Letter of Medical Necessity (LMN) from your child's doctor or therapist is the heart of almost every winning appeal. A weak LMN says 'patient needs a wheelchair.' A strong one connects your child's specific diagnosis to specific functional needs and explains why lesser or cheaper options will not work.
Ask the prescriber to name the diagnosis, describe what your child cannot safely do without the equipment (sit upright, stand for bone health, communicate, eat safely, move between rooms), state why alternatives were tried or ruled out, and tie it all to the plan's own medical-necessity criteria if you have that policy in hand. Concrete detail beats adjectives every time: 'requires trunk support to maintain a seated position for meals and schoolwork' lands harder than 'severely disabled.'
You are allowed to help. Many families draft the functional details they see every day at home and hand that to the clinician to review, edit, and put on letterhead. The physical therapist, occupational therapist, or speech-language pathologist who did the evaluation is often the best author for equipment in their area.
Know which rules protect your child
If your child has Medicaid, one rule is a powerful ally: EPSDT (Early and Periodic Screening, Diagnostic, and Treatment). Under EPSDT, state Medicaid programs must cover services and equipment that are medically necessary to correct or improve a condition for children under 21, even if that item is not covered for adults or is not on a standard adult list. If a Medicaid denial suggests an item 'is not covered,' EPSDT is often the exact ground you cite in your appeal.
Many children also have coverage through a Medicaid Home and Community-Based Services (HCBS) waiver, which can pay for equipment and modifications that regular plans skip. Rules and covered items vary a great deal by state, so confirm the specifics with your state Medicaid agency or your waiver case manager.
With private or employer insurance, your rights come from your plan documents and, for many plans, federal and state appeal protections that guarantee both an internal appeal and an independent external review. The denial letter and your Summary of Benefits will spell out your specific rights.
Build your evidence packet
Think of your appeal as a small, organized case file. Strong packets usually include: the prescription or order for the equipment; the Letter of Medical Necessity; the evaluation notes from the therapist or physician; relevant clinic or hospital records that show the diagnosis and history; and, when helpful, photos or a report from an equipment trial showing the item working for your child.
Add a short cover letter in plain language that says who your child is, what equipment was denied, the denial reason you are answering, and a clear request to overturn the decision. Number your attachments and reference them so a busy reviewer can follow along. Keep the tone calm and factual; you do not need to sound like a lawyer.
Keep a copy of everything, and log every phone call with the date, the name of the person you spoke with, and what they said. If you submit by portal or fax, save the confirmation. This record protects you if anything gets 'lost' or if you need to escalate.
If the first appeal is denied, keep going: escalation usually works in your favor
A second denial is still not the end. Two moves often turn things around. First, request a peer-to-peer review, where your prescriber speaks directly with the insurer's reviewing physician. Doctor-to-doctor conversations resolve many equipment disputes that paperwork alone could not.
Second, use your formal escalation rights. For Medicaid, that is a State Fair Hearing, where an independent officer reviews your case; you have the right to request one, and free legal aid or a disability rights organization can represent you at no cost. For private plans, that is typically an external review by an independent medical reviewer whose decision the insurer must follow.
This is where free help matters most. Every state has a Medicaid ombudsman or beneficiary help line, a federally funded Protection and Advocacy (P&A) agency, and legal aid programs that handle denials. You do not have to fight this alone, and using them costs nothing.
While you appeal, line up backup funding so a delay never leaves your child without equipment
Appeals take time, and your child's needs do not pause. Run a parallel track. AT Act assistive technology programs in every state often run device loan closets and reuse programs that can lend equipment, such as a wheelchair or communication device, while you wait. Ask your therapist or your state's assistive technology program.
For gap funding, real charities help families with medical equipment case by case. The UnitedHealthcare Children's Foundation offers grants for children's medical needs (you do not have to be a UnitedHealthcare member), First Hand Foundation helps with children's health-related expenses, and Variety - the Children's Charity funds adaptive equipment and mobility devices in many regions. Eligibility and covered items vary, so read each program's current guidelines.
Keep appealing even if a charity or loan closet bridges the gap. Winning the appeal is what secures long-term coverage, including future repairs and replacements as your child grows.
Your options while you fight the denial
| Option | Best for | Speed | Effort |
|---|---|---|---|
| Internal appeal | Overturning the denial itself | Weeks | Moderate - paperwork + LMN |
| Peer-to-peer review | Medical-necessity disputes | Fast once scheduled | Low for you; prescriber leads |
| State Fair Hearing / external review | Repeated denials | Weeks to months | Higher; free advocates can help |
| AT Act loan closet | Equipment to use right now | Days to weeks | Low - a phone call |
| Charity grant (UHCCF, First Hand, Variety) | Bridging cost gaps | Weeks | Moderate - application |
Everything in an appeal is fixable except a missed deadline. The moment your denial letter arrives, find the appeal deadline, write it on your calendar, and set a reminder for several days before. If you are still gathering documents, submit a short appeal on time anyway and note that supporting records will follow. Being on time and thin beats being perfect and late.
Frequently asked questions
How many times can I appeal one denial?
The letter says the equipment is 'not medically necessary.' Is that the final word?
My child has Medicaid and was told the item 'isn't covered.' Is there anything I can do?
Do I have to write the medical letter myself?
Can I get help without paying a lawyer?
What can my child use while the appeal drags on?
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