Advance Determination of Medicare Coverage (ADMC)
Section 1834(a)(15)(C) of the Social Security Act provides that carriers shall, at the request of a supplier or beneficiary, determine in advance of delivery of an item whether payment for the item may not be made because the item is not covered if:
- The item is a customized item,
- The beneficiary to whom the item is to be furnished, or the supplier, requests that such advance determination be made, and
- The item is not an inexpensive item as specified by the Secretary.
Several DME items are customized and are quite costly to purchase, therefore beneficiaries and suppliers can request an Advance Determination of Medicare Coverage (ADMC). It is important to note that ADMCs are not initial determinations as defined at 42 CFR 405.801(a), because no request for payment is being made. As such, an ADMC cannot be appealed.
This is a voluntary program. Beneficiaries and suppliers are not required to submit ADMC requests, in order to submit claims for items. Additionally, DME MACs may not require an ADMC request as a prerequisite for submitting a claim.
Manual wheelchairs eligible for an ADMC
- E1161, K0005, K0008 and K0009
Power wheelchairs eligible for ADMC
- A Group 2, 3 or 5 Single Power Option or Multiple Power Options wheelchair (K0835-K0843, K0856-K0864, K0890-K0891) – whether or not a power seating system will be provided at time of initial issue
- A Group 3 No Power Option wheelchair (K0848-K0855) that will be provided with an alternative drive control interface at time of initial issue
- Custom motorized/power wheelchair base (K0013)
Once a request is received, the DME MAC shall determine if there is sufficient medical documentation that supports whether the item is reasonable and necessary. In addition, a review of the beneficiary's claims' history should be conducted in order to determine whether any other reason exists to cause the claim to be denied, e.g., whether same or similar equipment has already been provided.
Upon receipt of a request, the DME MAC shall render an advance determination of Medicare coverage within 30 calendar days. DME MACs shall provide the requestor with their decision, be it affirmative or negative, in writing.
Requests for appropriate items received without documentation to support coverage will be denied as not meeting the medical necessity requirements Medicare has established for the item.
Upon receiving an ADMC, the DME MAC will review the information submitted with the request to determine if:
- A benefit category exists,
- A statutory exclusion exists, and
- The item is reasonable and necessary.
An approved ADMC decision will provide the supplier and the beneficiary assurance that the beneficiary, based on the information submitted with the request, will meet the medical necessity requirements Medicare has established for the item. An approved ADMC decision does not provide assurance that the beneficiary meets Medicare eligibility requirements, nor does it assure that any other Medicare requirements (MSP, etc.) have been met. Only upon submission of a complete claim can the DME MAC make a full and complete determination. An approved ADMC decision also does not extend to the price that Medicare will pay for the item.
A KX modifier may be added to the code on the claim for a power mobility device for an affirmative ADMC decision.
An affirmative ADMC decision is valid for a period of six months from the date the decision is rendered. Oftentimes, beneficiaries who require customized DME are subject to rapid changes in medical condition. These changes may allow the need for a particular item, either because the beneficiary's condition improved or deteriorated. For this reason, the date the item was provided to the beneficiary cannot be more than six months after the date the ADMC decision was made.
A negative ADMC decision communicates to the supplier and the beneficiary that, based on the information submitted with the request, the beneficiary does not meet the medical necessity requirements Medicare has established for the item. The negative ADMC decision should indicate why the request was denied.
Requests may be resubmitted once during a six month period for a negative ADMC decision if additional medical documentation is supplied.
Call our Supplier Contact Center with any additional questions regarding the ADMC process or any negative or affirmative decisions.
Last Updated Jun 28, 2016