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. § 405.1062

Applicability of local coverage determinations and other policies not binding on the ALJ or attorney adjudicator and Council

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(a) ALJs and attorney adjudicators and the Council are not bound by LCDs, LMRPs, or CMS program guidance, such as program memoranda and manual instructions, but will give substantial deference to these policies if they are applicable to a particular case.

(b) If an ALJ or attorney adjudicator or Council declines to follow a policy in a particular case, the ALJ or attorney adjudicator or Council decision must explain the reasons why the policy was not followed. An ALJ or attorney adjudicator or Council decision to disregard such policy applies only to the specific claim being considered and does not have precedential effect.

(c) An ALJ or attorney adjudicator or the Council may not set aside or review the validity of an LMRP or LCD for purposes of a claim appeal. An ALJ or the DAB may review or set aside an LCD (or any part of an LMRP that constitutes an LCD) in accordance with part 426 of this title.

[70 FR 11472, Mar. 8, 2005, as amended at 82 FR 5121, Jan. 17, 2017]
Notes of Decisions
Cited in 26 cases (16 in the last 5 years), 2009–2026 · leading case: Willie Goffney, Jr. v. Xavier Becerra, 995 F.3d 737 (9th Cir. 2021).
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Willie Goffney, Jr. v. Xavier Becerra, 995 F.3d 737 (9th Cir. 2021). “2010); see 42 C.F.R. § 405.1062 (a), it still shows that HHS’s interpretation is more than just a “convenient litigating position,” Christopher, 567 U.”
United States Ex Rel. Groat v. Boston Heart Diagnostics Corp., 255 F. Supp. 3d 13 (D.D.C. 2017). “Local coverage determinations, like national coverage determinations, govern Medicare coverage for a particular item or service.”
Finigan v. Burwell, 189 F. Supp. 3d 201 (D. Mass. 2016). · cites it 4× “42 C.F.R. § 405.1062 (emphasis supplied).”
Almy v. Sebelius, 679 F.3d 297 (4th Cir. 2012). “, 42 C.F.R. § 405.1062 (“If an ALJ or MAC declines to follow a policy in a particular case, .”
Ronald Fournier v. Kathleen Sebelius, 718 F.3d 1110 (9th Cir. 2013). “See 42 C.F.R. § 405.1062 (a) (“ALJs and the MAC are not bound by .”
Porzecanski v. Azar, 316 F. Supp. 3d 11 (D.C. Cir. 2018). “See 42 C.F.R. § 405.1062 . And although a local coverage determination may direct how contractors process certain billing codes, it cannot obviate the duty of administrative law judges and this Court to determine what the Medicare statute requires.”
Willowood of Great Barrington, Inc. v. Sebelius, 638 F. Supp. 2d 98 (D. Mass. 2009). “3)), but LCDs are not binding during the administrative process or before this court, 42 C.F.R. § 405.1062 (a). 3. Blood Glucose Tests and Medical Necessity Standards According to Defendant, the manner in which claims for payment of tests for blood glucose levels are evaluated…”
Odell v. Azar, 344 F. Supp. 3d 1192 (D. Nev. 2018). · cites it 2× “42 C.F.R. § 405.1062 (a). If an ALJ or the Council declines to follow an LCD, they must explain why.”
Thumann v. Sec'y, Dep't of Health & Human Servs. (S.D. Ohio 2021). · cites it 5× “§ 1395ff(c)(3)(B)(ii)(II); 42 C.F.R. § 405.1062 (a). Third, if the QIC denies coverage on reconsideration, the beneficiary may appeal the QIC’s reconsideration to an Administrative Law Judge (“ALJ”).”
I & R Med., P.C. v. Hargan (E.D.N.Y 2021). · cites it 4× “42 C.F.R § 405.1062(a). However, such policies must be given 2 A provider is “a hospital, critical access hospital, skilled nursing facility, comprehensive outpatient rehabilitation facility, home health agency, or hospice that has in effect an agreement to participate in…”
Townsend v. Azar (S.D.N.Y. 2021). · cites it 3× “§ 1395ff(c)(3)(B)(ii)(II); 42 C.F.R. §405.1062 (a). However, ALJs must give LCDs “substantial deference” if they are applicable, 42 C.”
Agendia Inc. v. Becerra (D.D.C. 2024). · cites it 3× “” 42 C.F.R. § 405.1062 (a). Any decision to “disregard such policy applies only to the specific claim being considered and does not have precedential effect.”
Show all 26 citing cases →
— 42 C.F.R. § 405.1062(a) — 2 cases
I & R Med., P.C. v. Hargan (E.D.N.Y 2021). “42 C.F.R § 405.1062(a). However, such policies must be given 2 A provider is “a hospital, critical access hospital, skilled nursing facility, comprehensive outpatient rehabilitation facility, home health agency, or hospice that has in effect an agreement to participate in…”
MacOmb Foot, Ankle & Wound Care v. Becerra (D.D.C. 2026).
— 42 C.F.R. § 405.1062(b) — 1 case
I & R Med., P.C. v. Hargan (E.D.N.Y 2021). “42 C.F.R § 405.1062(a). However, such policies must be given 2 A provider is “a hospital, critical access hospital, skilled nursing facility, comprehensive outpatient rehabilitation facility, home health agency, or hospice that has in effect an agreement to participate in…”
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