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. § 405.1100

Medicare Appeals Council review: General

Read at: eCFRecfr.gov CornellLII GovInfogovinfo.gov CasesGoogle Scholar

(a) The appellant or any other party to an ALJ's or attorney adjudicator's decision or dismissal may request that the Council review the ALJ's or attorney adjudicator's decision or dismissal.

(b) Under circumstances set forth in §§ 405.1016 and 405.1108, the appellant may request that a case be escalated to the Council for a decision even if the ALJ or attorney adjudicator has not issued a decision, dismissal, or remand in his or her case.

(c) When the Council reviews an ALJ's or attorney adjudicator's decision, it undertakes a de novo review. The Council issues a final decision or dismissal order or remands a case to the ALJ or attorney adjudicator within 90 calendar days of receipt of the appellant's request for review, unless the 90 calendar day period is extended as provided in this subpart.

(d) When deciding an appeal that was escalated from the OMHA level to the Council, the Council will issue a final decision or dismissal order or remand the case to the OMHA Chief ALJ within 180 calendar days of receipt of the appellant's request for escalation, unless the 180 calendar day period is extended as provided in this subpart.

[82 FR 5122, Jan. 17, 2017]
Notes of Decisions
Cited in 57 cases (25 in the last 5 years), 2010–2026 · leading case: Fam. Rehab., Inc. v. Azar, 886 F.3d 496 (5th Cir. 2018).
Sort: Relevance Newest Treatment
Fam. Rehab., Inc. v. Azar, 886 F.3d 496 (5th Cir. 2018). · cites it 2× “42 C.F.R. § 405.1100 . The Council reviews the ALJ's decision de novo and is similarly required to issue a final decision within 90 days.”
Sahara Health Care, Inc. v. Alex Azar, II, Secreta, 975 F.3d 523 (5th Cir. 2020). · cites it 2× “§ 1395ff(d)(2)(A); 42 C.F.R. §§ 405.1100 (c) (de novo re- view); 405.”
Med-Cert Home Care, LLC v. Azar, 365 F. Supp. 3d 742 (N.D. Tex. 2019). · cites it 2× “42 C.F.R. § 405.1100 (d). If the Medicare Appeals Council does not render a timely decision, the appealing party may seek judicial review in federal district court.”
Int'l Rehabilitative Sciences Inc. v. Sebelius, 688 F.3d 994 (9th Cir. 2012). · cites it 2× “42 C.F.R. § 405.1100 ; 42 U.S.C. § 1395ff(d)(2).”
Accident, Injury & Rehab v. Alex Azar, II, 943 F.3d 195 (4th Cir. 2019). “§ 1395ff(d)(2)(A), or within 180 days if the appeal had been escalated past the ALJ level, 42 C.F.R. § 405.1100 (d), the healthcare provider “may seek judicial review [in a United States district court], notwithstanding any requirements for a hearing for purposes of the party’s…”
Cumberland Cnty. Hosp. Sys., Inc. v. Burwell, 816 F.3d 48 (4th Cir. 2016). “§ 1395ff(d)(2)(A), or within 180 days if the appeal had been escalated past the ALJ level, 42 C.F.R. § 405.1100 (d), the'healthcare provider “may seek judicial review [in a' United States district court], notwithstanding any requirements for a hearing for purposes of the party’s…”
Gurpreet Padda v. Xavier Becerra, 37 F.4th 1376 (8th Cir. 2022). · cites it 2× “§ 1395ff(d)(2)(A); 42 C.F.R. § 405.1100 (a). If the ALJ does not issue a decision within the statutory period, the provider may escalate the case—that is, the provider may choose to skip review by the ALJ and proceed directly to review by the Appeals Council.”
Infinity Healthcare Servs., Inc. v. Azar, 349 F. Supp. 3d 587 (S.D. Tex. 2018). · cites it 2× “42 C.F.R. § 405.1100 . The Council reviews the ALJ's decision de novo and is similarly required to issue a final decision within 90 days.”
Almy v. Sebelius, 679 F.3d 297 (4th Cir. 2012). “§ 1395ff(d)(2)(B); 42 C.F.R. § 405.1100 (d), which is incompatible with BioniCare’s proffered notion that the MAC is somehow obligated to defer to the outcomes of prior decisions below.”
A1 Diabetes & Med. Supply v. Alex Azar II, 937 F.3d 613 (6th Cir. 2019). “Page 4 within 180 days from receipt of the party’s escalation request, 42 C.F.R. § 405.1100 (d). But that regulation appears to concern the timing of the Council’s decision, not the timing of escalation to district court.”
Edwin R. Banks v. Sec'y, Dep't of Health & Human Servs., 38 F.4th 86 (11th Cir. 2022). “§ 1395ff(d)(2); 42 C.F.R. § 405.1100 (a). And sixth, if the beneficiary is still unsatisfied with the result—or if the MAC doesn’t act in a timely manner—he can seek judicial review in federal court.”
Am. Hosp. Ass'n v. Sebelius, 76 F. Supp. 3d 43 (D.D.C. 2014). “See 42 C.F.R. § 405.1100 (c)-(d). If, however, the DAB cannot render a timely decision, a claimant may bypass it altogether and seek judicial review in federal *48 court so long as its claim meets an amount-in-controversy requirement (currently $1,430).”
Show all 57 citing cases →
— 42 C.F.R. § 405.1100(d) — 1 case
Wheelchair & Walker Rentals, Inc. v. Azar (W.D. Tex. 2019).
Annotations are extracted automatically from the opinions in the Syfert caselaw corpus and ranked by authority, recency, and treatment. Dots show Syfertize treatment of the citing case itself.