Advance Determination of Medicare Coverage (ADMC) of

5.18 – Advance Determination of Medicare Coverage (ADMC) of Customized DMEPOS (Rev. 10749; Issued: 05-11-21; Effective: 06-11-21; Implementation: 06-11-21) Section 1834(a)(15)(C) of the 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 patient 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. This section provides for direction in implementing §1834 (a)(15)(C) of the Act. 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, UPICs may not require an ADMC request as a prerequisite for submitting a claim.