C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 405—FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED › Subpart I—Determinations, Redeterminations, Reconsiderations, and Appeals Under Original Medicare (Part A and Part B)

42 C.F.R. § 405.1048

The effect of an ALJ's or attorney adjudicator's decision

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(a) The decision of the ALJ or attorney adjudicator on a request for hearing is binding on all parties unless—

(1) A party requests a review of the decision by the Council within the stated time period or the Council reviews the decision issued by an ALJ or attorney adjudicator under the procedures set forth in § 405.1110, and the Council issues a final decision or remand order or the appeal is escalated to Federal district court under the provisions at § 405.1132 and the Federal district court issues a decision.

(2) The decision is reopened and revised by an ALJ or attorney adjudicator or the Council under the procedures explained in § 405.980;

(3) The expedited access to judicial review process at § 405.990 is used;

(4) The ALJ's or attorney adjudicator's decision is a recommended decision directed to the Council and the Council issues a decision; or

(5) In a case remanded by a Federal district court, the Council assumes jurisdiction under the procedures in § 405.1138 and the Council issues a decision.

(b) The decision of the ALJ or attorney adjudicator on a request for review of a QIC dismissal is binding on all parties unless the decision is reopened and revised by the ALJ or attorney adjudicator under the procedures in § 405.980.

[82 FR 5119, Jan. 17, 2017]
Notes of Decisions
Cited in 12 cases (6 in the last 5 years), 2011–2026 · leading case: Randall D. Wolcott, Md, Pa v. Sebelius, 635 F.3d 757 (5th Cir. 2011).
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Randall D. Wolcott, Md, Pa v. Sebelius, 635 F.3d 757 (5th Cir. 2011). “See 42 C.F.R. §§ 405.1048 , 405.1130 (describing when an administrative appeals decision becomes binding on the parties).”
Ctr. for Dermatology & Ski v. Sylvia Mathews Burwell, 770 F.3d 586 (7th Cir. 2014). “42 C.F.R. §§ 405.1048 , 405.1100, 405.1104.”
Tangney v. Burwell, 186 F. Supp. 3d 45 (D. Mass. 2016). “See PL’s Reply 5, citing 42 C.F.R. §§ 405.1048 , 405.1130 ("The [Council’s] decision is final and binding on all parties [to the action.”
New Vision Home Health Care v. Anthem, Inc. (6th Cir. 2018). · cites it 3× “42 C.F.R. § 405.1048 . Fourth, and finally, the provider may appeal to the Council, which may enter a final decision or remand to the ALJ.”
Sanderson v. Sec'y of the United States Dep't of Health & Human Servs. (D. Kan. 2022). “14 42 C.F.R. § 405.1048 . 15 Id. § 405.1130.”
Townsend v. Azar (S.D.N.Y. 2021). “§1395ff(b)(1)(A); 42 C.F.R. §§ 405.1048 , 405.1136.8 STANDARD OF REVIEW Under Fed.”
Ashli Healthcare, Inc. v. Becerra (E.D. Cal. 2024). “See 42 C.F.R. §§ 405.1048 (a)(1), 8 405.1132.”
First United Methodist Church v. Becerra (D. Neb. 2022). “At the outset, the Court notes that neither party cited any case law in support of their respective positions on this specific point.”
Prosser v. Becerra (E.D. Wis. 2020). “42 C.F.R. § 405.1048 (a). The Council, a division of the Departmental Appeals Board of HHS, must review or dismiss the request within 90 days.”
Becerra (D. Or. 2025). “42 C.F.R. § 405.1048 (a). Having determined the Council erred, the Court also finds rehearing before the ALJ is not required upon remand in this case.”
Greiner Orthopedics, LLC v. Becerra (D.D.C. 2026). “at 3; see also 42 C.F.R. § 405.1048 (2017). The court agrees that it has jurisdiction to review those denials.”
Honey v. Bayhealth Med. Ctr., Inc. (Del. Super. Ct. 2015). “596 (reconsideration); 42 C.F.R. § 405.1048 (ALJ decision); 42 C.”
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