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Denied Again? Reading Your Medicare Denial Letter

Daryl Bullard·

You open the envelope, see the word "denied," and your stomach drops. I've had clients call me in tears over these letters. Here's the thing I want you to know first: most denials I see are fixable, and a surprising number of them aren't really denials at all.

Let's go through what you're actually holding.

First: Is this a real Medicare denial?

There are three very different pieces of paper that people call "the denial letter," and they mean completely different things.

A supplier saying no. This is the most common one, and it isn't Medicare at all. The DME company looked at your paperwork, decided the claim was risky, and never submitted it. No claim, no denial, no appeal rights. If you're holding a letter on the supplier's letterhead, you don't have a Medicare decision — you have a business decision.

An Advance Beneficiary Notice (ABN, Form CMS-R-131). This is the form they ask you to sign before delivery saying you'll pay if Medicare doesn't. Read the option boxes carefully. Option 1 means the claim still gets submitted and you keep your appeal rights. Option 2 means you pay out of pocket and nothing is ever filed. Suppliers often steer people toward Option 2. Choose Option 1 unless you genuinely never want to appeal.

A Medicare Summary Notice (MSN) or Remittance Advice. This is the real thing. It arrives quarterly, or the supplier gets an electronic version faster. This is what starts your appeal clock.

If you're in the first category, call the supplier and say: "Please submit the claim so I can receive a formal determination." They are generally required to file. You cannot appeal a phone call.

Reading the actual denial reason

On the MSN, look for the reason code and the plain-English note underneath. The ones I see over and over on manual wheelchair claims:

CO-50 — "not deemed a medical necessity." This usually means the documentation didn't support the code billed. For a K0005 ultralightweight chair, the coverage policy (LCD L33792) requires that you're a full-time manual wheelchair user and engaged in frequent activities that can't be performed in a K0001–K0004 chair. If your doctor's note says "patient needs a wheelchair for mobility," that's a denial waiting to happen. It needs to say what you actually do — transfers independently 15+ times a day, propels 1,500 feet across a college campus, self-loads the chair into a car, has a history of shoulder impingement documented on imaging.

CO-16 — "claim lacks information." Almost always a paperwork gap: missing standard written order, an order dated after delivery, a face-to-face encounter note outside the six-month window, or no detailed product description signed by the physician. This is the easiest kind to win because nothing about your medical need is in dispute.

CO-B7 or CO-B9 — supplier enrollment or hospice/Part A overlap problems. Not about you at all.

N-codes in the remarks column carry the detail. N130 points you to the specific coverage policy. Look it up — it tells you exactly what the reviewer wanted to see.

Your five levels, and the two that matter

  1. Redetermination — 120 days from the MSN date, filed with the MAC. Decision in 60 days.
  2. Reconsideration — 180 days, goes to a Qualified Independent Contractor.
  3. Administrative Law Judge hearing — 60 days to request, with a minimum amount in controversy (around $190 in 2025). Wait times have run a year or more.
  4. Medicare Appeals Council.
  5. Federal district court.

Honest tradeoff: Level 1 is cheap and fast, but it's often reviewed by the same contractor with the same eyes. Level 3, the ALJ hearing, is historically where beneficiaries win most often — because you get a live human who will listen to you describe your day. The cost is time. If you're going to fight, plan for the long haul and get the documentation right at Level 1 anyway, because that record follows you up the chain.

What to actually put in the appeal

Don't argue. Supply evidence. In my experience the appeals that win include:

  • A rewritten physician letter that tracks the coverage criteria language point by point
  • A therapist's seating and mobility evaluation with measurements, propulsion distances, and transfer counts
  • A statement from you describing a typical Tuesday in concrete terms
  • Photos of your home — the 30-inch doorway, the threshold, the bathroom you can't turn around in

Use Form CMS-20027 for redetermination, and CMS-1696 if you want someone to represent you.

If you're on Medicare Advantage, the rules are different. You have 60 days to appeal, and you can request an expedited decision answered within 72 hours if waiting would harm your health. Use that. It's badly underused.

One last thing: a denial is not a verdict on whether you need the chair. It's a verdict on a stack of paper. Fix the paper.

Ready for a Chair That Actually Fits?

Most denials trace back to documentation that never described the person in the chair. Getting the specification and the justification right the first time is the whole game.

I work directly with clients to specify and order custom ultra-lightweight wheelchairs — no middlemen, no upsells, just the chair that fits your life.

Get started at wheelchair.direct — answer a few questions and I'll reach out personally.