This is what CaseWhy Appeals writes for a case like this one; your letter uses your facts and your notice's rule.
September 27, 2026
Novitas Solutions — Medicare Redeterminations, PO Box 3060, Mechanicsburg, PA 17055
RE: Requesting a redetermination of the denial of the item or service described below under 42 CFR § 405.942 — Dorothy Sample, Medicare number ••••DEMO, denial dated 2026-08-05, Durable medical equipment denied (CPAP, oxygen, power mobility, hospital bed, diabetic supplies)
On 2026-08-05, your Medicare contractor denied the item or service described below. The stated reason was: "This item was denied because Medicare coverage criteria were not met."
I am appealing the denial of coverage for the durable medical equipment at issue on the grounds that your Medicare contractor has not properly applied the governing coverage standard. Under BPM Chapter 15 § 110, DME expenses are reimbursable when three requirements are met: the equipment meets the definition of DME, the equipment is necessary and reasonable for treatment of the patient's illness or injury or to improve functioning of a malformed body member, and the equipment is used in the patient's home. Your contractor's stated reason—that the item is "not reasonable and necessary"—does not address whether these three statutory requirements have been satisfied. The regulation at § 110 establishes that reasonableness and necessity are determined by reference to the patient's clinical condition and the functional purpose the equipment serves, not by categorical exclusion or blanket policy.
The specific coverage determinations governing this equipment type establish detailed criteria that define what constitutes a reasonable and necessary use. For example, NCD 240.4 regarding CPAP therapy specifies that coverage is determined by whether the patient meets defined clinical thresholds—such as an AHI or RDI greater than or equal to 15 events per hour, or specific combinations of lower event counts with documented symptoms—and whether appropriate diagnostic testing has been performed under physician supervision. Similarly, NCD 240.2 regarding home oxygen establishes that coverage depends on whether the patient exhibits hypoxemia as defined by specific arterial blood gas or oximetry measurements performed at the time of need. These NCDs demonstrate that Medicare's coverage standard requires application of clinical criteria to the individual patient's documented condition, not a determination that an item category is categorically unreasonable.
Your Medicare contractor's denial does not explain which specific requirement under the applicable coverage rule has not been satisfied, nor does it address the clinical evidence or documentation submitted in support of this claim. Under BPM Chapter 15 § 110 and the applicable National Coverage Determination, your contractor is required to evaluate whether the equipment serves a reasonable and necessary function for this patient's documented condition and home use. A denial based solely on the conclusory statement that an item is "not reasonable and necessary" without reference to the specific regulatory criteria and the evidence supporting or refuting those criteria does not constitute a reasoned application of Medicare coverage policy.
The facts as I understand them:
The sleep test was done before I got my CPAP.
The ordering practitioner saw me in person before ordering the equipment.
Requesting a redetermination of the denial of the item or service described below under 42 CFR § 405.942
Enclosures:
Physician letter (to follow)
Signed by the enrollee.