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Wheelchairs Eligible for Advance Determination of Medicare Coverage – Group 4 Power Wheelchairs Removed (A51530)

Advance Determination of Medicare Coverage (ADMC) is a process by which the Durable medical equipment Medicare administrative contractor (DME MAC) provides the supplier and beneficiary with a decision regarding the medical necessity for the item billed prior to submission of the claim and delivery of the product. Effective for ADMC request dates on or after January 1, 2012 the wheelchairs eligible for ADMC have changed.

Because of the February 2011 elimination of Least Costly Medically Appropriate Alternative, ADMC eligibility for Group 4 Power Wheelchairs (PWC) is eliminated. According to the Local Coverage Determination (LCD) for Power Mobility Devices, Group 4 PWC are considered not reasonable and necessary; therefore, no ADMC is possible for this category of PWC.

Group 4 PWC are often provided as an upgrade to a covered Group 2 or 3 PWC. The ADMC request should be submitted based upon the covered PWC base.

The following wheelchairs are eligible for ADMC:

  • Manual wheelchairs
    • E1161, K0005, and K0009
    • E1231-E1234
  • Power wheelchairs
    • Group 2 (K0835-K0843)
    • Group 3 (K0856-K0864)
    • Group 3 (K0848-K0855) provided with an alternative drive control interface (E2321-E2322, E2325, E2327-E2330)
    • Group 5 (K0890, K0891)

The Power Mobility LCD will be updated in a future revision.

Refer to the Jurisdiction B DME MAC Supplier Manual and the Power Mobility Devices LCD and related Policy Article for additional information about the ADMC process.

Wheelchairs Eligible for Advance Determination of Medicare Coverage - Group 4 Power Wheelchairs Removed (A51530)
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