License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

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Advanced Determination of Medicare Coverage (ADMC)

Updated: 02.16.24

Topics

What is Advanced Determination of Medicare Coverage (ADMC)?
Eligible Items
Rejections
2nd Submissions
Time Frames
Appeal Rights
ADMC Submissions
Resources

What is Advanced Determination of Medicare Coverage (ADMC)?

Advance Determination of Medicare Coverage (ADMC) is a voluntary program that allows Suppliers and Beneficiaries to request prior approval of "eligible" items before delivery of the items to the beneficiary. At this time, only customized wheelchairs (manual and power) are eligible for ADMC. Approval applies to the medical necessity of the item and does not guarantee that the claim will be paid. Other claim edits, such as Medicare eligibility, could cause the claim to deny even though ADMC approved the item.

Eligible Items

ADMC is available as an option only for the following wheelchair base HCPCS codes:

HCPCS Code	Type of Base
E1161	Manual adult size wheelchair, includes tilt in space
E1231 – E1234	Manual pediatric size wheelchair, includes tilt in space
K0005	Manual adult size wheelchair, ultra lightweight
K0008	Custom manual wheelchair/base
K0009	Manual adult size wheelchair, not otherwise classified
K0013	Custom Motorized/Power Wheelchair Base
K0890 – K0891	Power pediatric size wheelchair, group 5 – Single or Multiple power options

When a particular wheelchair base is eligible for ADMC, all wheelchair options and accessories ordered by the physician for that patient along with the base HCPCS code will be eligible for ADMC.

Rejections

ADMC requests are reviewed to determine whether or not they meet the requirements for ADMC requests. A rejection is NOT a denial. Reasons to reject an ADMC request include: ineligible items, requests that exceed the limit of 2 within 6 months, the beneficiary does not live within Jurisdiction B., there are no item codes and/or descriptions listed on the requests, demographics are missing, the place of service is either a hospital or a skilled nursing facility, there are two different wheelchair bases listed on the request, the request is a duplicate of a previous submission, a faxing error occurred, the item requested is not a wheelchair and/or the request is for denied accessories and/or additional accessories associated with a previously approved wheelchair base.

If the request is rejected then a letter will be mailed to the supplier and the beneficiary within 30 days explaining why the request was rejected. Another request may be resubmitted along with any additional and/or corrected documentation. There is no time limit for rejections.

2nd Submissions

While a negative ADMC decision cannot be appealed, an ADMC request can be resubmitted if the wheelchair base is denied and additional medical documentation is obtained. ADMC requests may only be resubmitted once during the six-month period following a negative determination. If the wheelchair base is approved, but one or more accessories are denied, an ADMC request may not be resubmitted for those accessories or any additional accessories.

If you provide a wheelchair and/or accessories following a negative determination, a claim for the item should be submitted. If new information is provided with the claim, coverage will be considered. If the claim is denied, it may be appealed through the usual process (see the Supplier Manual, Chapter 13 for information about appeals).

Time Frames

Upon receipt of an ADMC request, a determination will be made within 30 calendar days. The Medical Review clinician will provide you and the beneficiary with a determination, either rejection, affirmative or negative, in writing. If it is a negative determination, the letter will indicate why the request was denied - e.g., not medically necessary, insufficient information submitted to determine coverage, statutorily non-covered.

If a wheelchair base receives a negative determination, all accessories will also receive a negative determination. If a wheelchair base receives an affirmative determination, each accessory will receive an individual determination.

An affirmative ADMC is only valid for items delivered within six months following the date of the determination. If the wheelchair is not delivered within that time, you have the option of either submitting a new ADMC request (prior to providing the item) or filing a claim (after providing the item).

Appeal Rights

There are NO appeal rights on ADMC decisions. (The claim can be appealed only after it is processed.)

ADMC Submissions

myCGS:

The fastest, easiest way to submit ADMC requests is through the DME myCGS portal.

If you are not yet registered for myCGS, get started with the myCGS Registration and Account Management Guide.
If you are already registered for myCGS, refer to the "ADMC" section in Chapter 5 of the myCGS User Manual.

Fax or Mail:

Clearly indicate "ADMC" on the first page of all requests. Include demographic information such as: the beneficiary's Medicare number (MBI-Medicare Beneficiary Identifier), the beneficiary's address, the beneficiary's date of birth, the base wheelchair item code and description, any accessory item numbers (HCPCS) and their descriptions, ICD-10 diagnosis codes, place of service, physician information, supplier information, National Supplier Clearinghouse number (NSC) and the National Provider Identification number (NPI). For your convenience, CGS has prepared an ADMC request form that can be completed and used as a cover sheet. Submit your requests in writing by mail or fax to:

CGS
ATTN: ADMC
P.O. Box 20007
Nashville, TN 37202
FAX: 615 660.5988

For additional information concerning the ADMC process and required documentation, please refer to Chapter Nine, Section 4 of the Jurisdiction B Supplier Manual.