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Non-covered Services/Category III CPT Code Utilization ADR Checklist

CGS recommends providers organize the medical documentation in the order indicated below. This will assist CGS in reviewing your documentation more efficiently and will expedite the review process. Please ensure the documentation is submitted within 45 days of the Additional Documentation Request (ADR). If the documentation has not been received, the claim will automatically deny on the 46th day for non-receipt of documentation.

Providers should submit all documentation that is pertinent to support the medical necessity of services for the billing period being reviewed. Ensure services billed are coded accurately for the service provided and the documentation supports those services. This may include documentation that is prior to the review period. Please note that the most common reason for overturned appeals is due to providers submitting new documentation upon the appeal that was omitted with the initial submission of medical records.

*Please include the beneficiary name and date of service on all documentation and include an abbreviation key (if applicable). Documentation must be legible and complete (including signature(s) and date(s)). If you question the legibility of your signature, you may submit a signature log or an attestation statement.

The Checklist below is intended to be utilized by providers as a reference when responding to Additional Documentation Requests (ADRs) to ensure each claim meets the policy requirements prior to the ADR submission. Please submit all documentation as required in the LCD or NCD, if applicable, and in accordance with the Medicare Benefit Policy Manual. It is the responsibility of the provider to submit complete and accurate documentation per the regulatory guidelines for each claim. Ensure the documentation submitted belongs solely to the intended beneficiary and documentation of another beneficiary is not present within any aspect of the medical record.

Please submit a copy of the ADR letter and enclosed cover sheet with each appropriate DCN to separate applicable documentation for review. Please ensure you include a designated point of contact (name, email, telephone number) with all records submitted in response to each ADR. CGS may contact this individual for an easily curable error identified during the review process in order to prevent a claim denial for missing documentation.

Click on the table below for a printable version.


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Providers may include an outline or cover letter with their documentation. This can be used by CGS Medical Review staff as an Index and prove very helpful to provide the location of key documentation that supports payment of the claim. However, the cover letter cannot be used as documentation, and the documentation must support the contents of the cover letter in order to be useful.

In addition, providers may use brackets, such as [ ] or { }, asterisks (*) or underlined text in the documentation to draw the reviewer's attention to important information. However, notations should not alter, or give the appearance of altering, the documentation. The use of a highlighter is not recommended as documentation may not be legible.

We encourage all CGS providers to utilize the myCGS Portal, a free service available 24/7, which offers access to beneficiary eligibility, claim and payment information, forms allowing you to submit redetermination requests, and respond to Medical Review Additional Documentation Requests (ADRs) and much more. Please enroll for myCGS if you have not already done so.

Check the Calendar of Events to sign up for any webinars that may be of interest.

Please contact for further questions, concerns, or educational needs related to this review. Be sure to include the facility name and provider number/PTAN for the inquiry. Ensure CGS is current with provider contact information for any educational outreach opportunity.


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