How does Counterclaim generate an insurance appeal letter?

Counterclaim uses a 5-agent AI pipeline. The Reader extracts claim data from your document. The Researcher identifies applicable state insurance law. The Writer drafts a formal appeal letter. The Adversary identifies weaknesses. The Editor rewrites the letter to eliminate all weaknesses. The final letter is ready to print and mail in minutes.

Is Counterclaim free to use?

Yes - Counterclaim is free during the launch period. Upload your denial letter and receive a complete adversary-tested appeal letter at no cost. No account required.

What types of insurance denials can Counterclaim handle?

Counterclaim handles all major denial types: medical necessity (CO-50), prior authorization (CO-11), experimental treatment (PR-1), fee schedule (CO-45), timely filing (PR-27), not covered (CO-4), step therapy (PR-50), and missing information (CO-16).

What file formats does Counterclaim accept?

Counterclaim accepts PDF files, JPG and PNG photos, and scanned documents of your denial letter or Explanation of Benefits (EOB).

Does Counterclaim provide legal advice?

No. Counterclaim generates appeal letters based on publicly available legal and clinical information but does not constitute legal advice. For complex cases, consult a licensed healthcare attorney or certified patient advocate.

Can I appeal a Medicare DME denial?

Yes. Medicare DME denials are appealable through five levels: redetermination by the DME MAC, reconsideration by a Qualified Independent Contractor, hearing before an Administrative Law Judge, Medicare Appeals Council review, and federal court. You have 120 days from the initial denial to request redetermination. For Medicare Advantage, the path is plan reconsideration, IRE review by C2C or Maximus, then ALJ.

What is the 13-month DME rental cap?

Under Medicare DMEPOS rules, capped-rental items (including most wheelchairs and hospital beds) convert to beneficiary ownership after 13 months of continuous rental. If your insurer is denying month 14 of rental, the issue is usually that the item should have already converted. Quote the capped-rental category in your appeal.

Why was my power wheelchair denied when my doctor prescribed it?

Power Mobility Devices (PMDs, HCPCS K0813-K0891) trigger the strictest documentation requirements. Plans typically require the face-to-face evaluation to address the seven-element mobility evaluation: chief complaint, history, physical exam, prior mobility devices tried, mobility-related activities of daily living, home assessment, and equipment justification. Missing any element is the most common reason for denial. Have your prescribing physician produce a corrected note that explicitly addresses each element.

My CPAP supplies were denied as 'too frequent' - is that legal?

Medicare publishes a CPAP Supplies Replacement Schedule that allows a new mask every 3 months, cushions twice a month, and a new CPAP machine after 5 years. If your replacement is within the schedule, the denial should be overturned by quoting the replacement schedule directly. Commercial plans either follow Medicare or publish a similar schedule in their policy.

Does the DME supplier appeal on my behalf?

Many accredited DME suppliers will pursue the first-level appeal because they are the entity that submitted the claim. However, you have an independent right to appeal as the beneficiary, and submitting your own letter (with physician documentation) often produces a stronger record than the supplier's standard form letter. The two efforts can run in parallel.

What documentation does an Advance Beneficiary Notice (ABN) change?

If you signed an ABN before receiving an upgraded item, you agreed in writing to be financially responsible if Medicare denies. The ABN does not waive your right to appeal, but it does shift the financial risk if the appeal fails. Always keep a copy of any ABN you signed and reference it in your appeal.

Can I appeal a Medicaid DME denial through a fair hearing?

Yes. Under 42 CFR section 431.220, every Medicaid beneficiary has the right to a state fair hearing on any benefit denial. Request the hearing in writing within the timeframe your state Medicaid agency specifies (typically 60 to 90 days). Medicaid DME hearings often succeed when EPSDT (Early and Periodic Screening, Diagnostic and Treatment) protections apply for beneficiaries under 21.

DME

Durable Medical Equipment (DME) Insurance Denial Appeal — Free AI Letter

Insurance denied your wheelchair, hospital bed, CPAP, or other durable medical equipment? Generate a free, evidence-backed appeal letter in minutes.

Why durable medical equipment (dme) denials happen so often

Durable Medical Equipment (DME) covers items prescribed by your physician for use in the home: manual and power wheelchairs, hospital beds, CPAP and BiPAP machines, oxygen concentrators, glucose monitors, prosthetics, orthotics, ostomy and urological supplies, and patient lifts. Medicare and most commercial plans cover DME under a separate benefit category from physician services, with its own prior-authorization rules, supplier network, and rental-versus-purchase pricing schedule. That separation is exactly why DME denials happen so often: the equipment your doctor prescribes does not match the narrow definition the payer has written into its DME policy, the supplier was not in-network or accredited the way the plan requires, or the documentation in your face-to-face evaluation does not include the precise functional language the auditor was looking for. The good news is that DME denials are appealable, frequently winnable, and the evidence requirements are well-established by Medicare's Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs), which most commercial plans mirror almost word-for-word.

Why DME gets denied

Not medically necessary for the patient's documented condition (most common reason cited)

Missing or incomplete face-to-face encounter note within the required look-back window (Medicare requires the visit within 6 months for most DME)

Standard Written Order (SWO) lacks one of the five required elements: beneficiary name, item description, prescribing practitioner name and NPI, signature, and date

Capped-rental item exceeded the 13-month rental cap (Medicare converts most capped-rental DME to beneficiary ownership after month 13)

Supplier not enrolled in Medicare or not accredited; commercial plans similarly require in-network DMEPOS suppliers

Item categorized as a 'convenience' or 'comfort' item rather than medically necessary (e.g. shower chairs, stair lifts, exercise equipment)

Upgraded equipment denied as exceeding the basic medical need (Medicare's Advance Beneficiary Notice / ABN process applies)

Federal and state protections for DME

DME coverage is governed by your plan's contract plus, for Medicare beneficiaries, 42 CFR Part 414 Subpart D (DMEPOS payment) and the relevant Local Coverage Determinations issued by the four DME Medicare Administrative Contractors (CGS, Noridian, NHIC, and CGS Jurisdiction C). Commercial plans regulated by the ACA must provide an internal appeal and an external review by an Independent Review Organization under 45 CFR section 147.136. Medicare Advantage members appeal through the plan's reconsideration process, then automatically to the Independent Review Entity (IRE) administered by C2C Innovative Solutions or Maximus. Self-funded ERISA plans are bound by 29 CFR section 2560.503-1 and must provide a full and fair review including the criteria used and the reviewer's clinical credentials. State Medicaid DME denials are governed by 42 CFR section 431.220 fair-hearing rights.

Evidence checklist for your appeal

The treating physician's face-to-face encounter note, dated within the LCD's required look-back period and addressing the specific functional impairment
Standard Written Order with all five required elements legible and dated before delivery
Letter of Medical Necessity from the prescribing physician explaining why the requested HCPCS code (not a lower-level alternative) is required
Copies of any prior unsuccessful trials of less expensive alternatives (e.g. trial of a manual wheelchair before requesting a power mobility device)
The plan's own DME coverage policy with the criteria-met paragraph highlighted
Photographs of the home environment if relevant to the medical necessity (e.g. doorway widths for power wheelchairs, head-of-bed elevation needs)
Supplier's accreditation certificate and Medicare DMEPOS enrollment if disputed

Common billing codes

E0260 (semi-electric hospital bed)
E0140 (walker with seat)
E0601 (CPAP device)
E0470 (BiPAP, no backup rate)
E0570 (nebulizer)
K0001 (standard manual wheelchair)
K0823 (power wheelchair, Group 2 standard)
L1832 (knee orthosis)

Common products

ResMed AirSense (CPAP)
Philips Respironics DreamStation
Invacare and Drive Medical wheelchairs
Permobil and Quantum power chairs
Hill-Rom hospital beds
Inogen and Caire portable oxygen concentrators

Insurer-specific patterns and tactics

UnitedHealthcare delegates much of its commercial DME prior authorization to Optum, which the AMA's 2024 Prior Authorization Physician Survey identified as one of the highest-volume PA programs in the country. Aetna and Anthem both have published DME clinical bulletins (Aetna Clinical Policy Bulletins 0297, 0421, 0469 for various DME categories; Anthem CG-DME series) that you should quote back at them by exact bulletin number. Cigna routes DME through Evernorth and applies its own coverage policies, often denying CPAP supplies more than once every three months as 'maintenance.' For Medicare Advantage members, the October 2024 Senate Permanent Subcommittee on Investigations report documented elevated DME denial rates at the three largest MA insurers and is itself usable as appeal-letter context.

Generate your DME appeal letter

Upload your denial notice or EOB. Our 5-agent AI pipeline drafts a professional appeal that cites the specific statute, clinical policy, and evidence pattern relevant to a dme denial - in about 2 minutes, free.

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Frequently asked questions: DME appeals

Appeal a Physical Therapy denial

Appeal a Occupational Therapy denial

Appeal a Speech Therapy denial

Appeal a Home Health Care denial

Appeal a Skilled Nursing Facility (SNF) denial

Appeal a Infusion Therapy denial

Related insurer guides

UnitedHealthcare appeals

Aetna appeals

Cigna appeals

Anthem appeals

Related denial codes

CO-50

Medical Necessity Denial (CO-50)

CO-11

Prior Authorization Denial (CO-11)