Q.) What kind of documentation needs to be submitted with an ADMC request for a K0005 wheelchair?
A.) In addition to the usual policy requirements of a complete and valid CMN, as well the Local Medical Review Policy (LMRP/LCD) for manual wheelchair bases states: Coverage of an ultralightweight wheelchair (K0005) is determined on an individual consideration basis. Documentation for individual consideration might include information on the patient's diagnosis, the patient's abilities and limitations as they relate to the equipment (e.g., degree of independence/dependence, frequency, and nature of the activities the patient performs, etc.), the duration of the condition, the expected prognosis, and past experience using similar equipment.
Initial claims for K0005 must include a description of the patient's routine activities. This may include what types of activities the patient frequently encounters, and whether the patient is fully independent in the use of the wheelchair. Describe the features of the K0005 base which are needed compared to the K0004 base. This information should be attached to a hard copy claim or entered in the narrative field of an electronic claim.
Q.) If my ADMC request was denied, when can I resubmit another request?
A.) In cases where an ADMC request was negative (denied), a beneficiary or a supplier may resubmit a request if additional medical documentation is obtained that could affect the prior negative ADMC decision. However, requests may only be submitted once during a 6-month period.
Q.) In September 1999 the DMERC published an article, Timeliness of CMNs, which described the requirement that,
"... if greater than 3 months passes from the time a CMN is completed and signed by the physician and the item being ordered is delivered, a new CMN will have to be completed and signed for submission of a claim...".
The instructions for ADMC, published in June 2001, state,
" An affirmative ADMC is only valid for items delivered within 6 months following the date of the determination. If the wheelchair is not delivered within that time, the supplier has the option of either submitting a new ADMC request (prior to providing the item) or filing a claim (after providing the item).
These two requirements appear to contradict one another by allowing different intervals for the validity of a CMN. Can you resolve this apparent contradiction?
A.) The September 1999 article describes the general requirements applicable to all items requiring a CMN, most of which do not make use of the ADMC process. The ADMC process allows for a longer interval and supercedes the timeframe set in the 1999 article only for those items for which a valid ADMC determination has been made.
Thus, if an affirmative ADMC was received for the item, and the item was delivered to the patient after 90 days, a new initial CMN is not needed because the ADMC allows for delivery within 6 months.
If the item did not go through the ADMC process and was delivered after 90 days, a new initial CMN is required to establish that the item is medically necessary. (CR 1187, 1773)
Q.) What does TriCenturion look for when making a determination on an ADMC Request?
A.) TriCenturion reviews the documentation submitted with the request and determines if there is sufficient medical documentation that supports whether the item is reasonable and necessary. In addition, the PSC reviews the beneficiary’s claim(s) history in order to determine whether the same or similar equipment has already been provided.
Q.) How are providers notified of the determination that is made by TriCenturion?
A.) TriCenturion will send a letter called the Notice of Determination to the provider for both affirmative (approved) or negative (denied) determinations within 30 calendar days of receipt of the request.
Q.) How should we submit for an ADMC when the beneficiary wants an upgrade?
A.) You should submit the HCPCS that correctly corresponds to the item you are providing the beneficiary and the HCPCS for which you are requesting Advanced Determination, along with documentation that explains the upgrade situation. If you receive a positive determination, you should bill the item as an upgrade. You can refer to Newsletter #60 December 2001 for how to bill for upgrades.