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. § 405.1136

Judicial review

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

(a) General rules. (1) To the extent authorized by sections 1869, 1876(c)(5)(B), and 1879(d) of the Act, a party to a Council decision, or an appellant who requests escalation to Federal district court if the Council does not complete its review of the ALJ's or attorney adjudicator's decision within the applicable adjudication period, may obtain a court review if the amount remaining in controversy satisfies the requirements of § 405.1006(c).

(2) If the Council's adjudication period set forth in § 405.1100 expires and the appellant does not request escalation to Federal district court, the case remains with the Council until a final decision, dismissal order, or remand order is issued.

(b) Court in which to file civil action. (1) Any civil action described in paragraph (a) of this section must be filed in the district court of the United States for the judicial district in which the party resides or where such individual, institution, or agency has its principal place of business.

(2) If the party does not reside within any judicial district, or if the individual, institution, or agency does not have its principal place of business within any such judicial district, the civil action must be filed in the District Court of the United States for the District of Columbia.

(c) Time for filing civil action. (1) Any civil action described in paragraph (a) of this section must be filed within the time periods specified in § 405.1130, § 405.1132, or § 405.1134, as applicable.

(2) For purposes of this section, the date of receipt of the notice of the Council's decision or the Council's notice that it is not able to issue a decision within the statutory timeframe shall be presumed to be 5 calendar days after the date of the notice, unless there is a reasonable showing to the contrary.

(3) Where a case is certified for judicial review in accordance with the expedited access to judicial review process in § 405.990, the civil action must be filed within 60 calendar days after receipt of the review entity's certification, except where the time is extended by the ALJ or attorney adjudicator or Council, as applicable, upon a showing of good cause.

(d) Proper defendant. (1) In any civil action described in paragraph (a) of this section, the Secretary of HHS, in his or her official capacity, is the proper defendant. Any civil action properly filed shall survive notwithstanding any change of the person holding the Office of the Secretary of HHS or any vacancy in such office.

(2) If the complaint is erroneously filed against the United States or against any agency, officer, or employee of the United States other than the Secretary, the plaintiff will be notified that he or she has named an incorrect defendant and is granted 60 calendar days from the date of receipt of the notice in which to commence the action against the correct defendant, the Secretary.

(e) Prohibition against judicial review of certain Part B regulations or instructions. Under section 1869(e)(1) of the Act, a court may not review a regulation or instruction that relates to a method of payment under Medicare Part B if the regulation was published, or the instructions issued, before January 1, 1991.

(f) Standard of review. (1) Under section 205(g) of the Act, the findings of the Secretary of HHS as to any fact, if supported by substantial evidence, are conclusive.

(2) When the Secretary's decision is adverse to a party due to a party's failure to submit proof in conformity with a regulation prescribed under section 205(a) of the Act pertaining to the type of proof a party must offer to establish entitlement to payment, the court will review only whether the proof conforms with the regulation and the validity of the regulation.

[70 FR 11472, Mar. 8, 2005, as amended at 70 FR 37705, June 30, 2005; 74 FR 65338, Dec. 9, 2009; 82 FR 5124, Jan. 17, 2017]
Notes of Decisions
Cited in 32 cases (19 in the last 5 years), 2008–2026 · leading case: Gen. Med., P.C. v. Alex Azar, 963 F.3d 516 (6th Cir. 2020).
Sort: Relevance Newest Treatment
Gen. Med., P.C. v. Alex Azar, 963 F.3d 516 (6th Cir. 2020). “1994); 42 C.F.R. § 405.1136 (f). “Substantial evidence is more than a scintilla of evidence but less than a preponderance; it is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.”
Med-Cert Home Care, LLC v. Azar, 365 F. Supp. 3d 742 (N.D. Tex. 2019). “42 C.F.R. § 405.1136 (a)(1). Second, the standard of review exercised by a district court on appeal would be different than that of an ALJ.”
A1 Diabetes & Med. Supply v. Alex Azar II, 937 F.3d 613 (6th Cir. 2019). “§ 1395ff(b)(1)(A); 42 C.F.R. § 405.1136 (a)(1). If at the end of this long journey the provider successfully shows the district court that it charged the right amount all along, the government must pay back whatever it collected plus interest.”
True Health Diagnostics, LLC v. Azar, 392 F. Supp. 3d 656 (E.D. Tex. 2019). “§ 1395ff(b)(1)(A) ; 42 C.F.R. § 405.1136 ; 42 C.F.R. § 405.1130 .”
North Carolina Ins. Guar. Ass'n v. Xavier Becerra, 55 F.4th 428 (4th Cir. 2022). “42 C.F.R. § 405.1136 . B. On June 1, 2020, Appellant sent a letter to CMS (“Appellant’s Letter”), requesting a written opinion stating that Appellant is not a primary plan within the meaning of the MSPA, and, as a result, is not required to comply with the reporting requirements…”
Almy v. Sebelius, 749 F. Supp. 2d 315 (D. Maryland 2010). “§ 1395ff(b)(l)(A); 42 C.F.R. § 405.1136 . IV. Bionicare’s Claims for the BIO-1000 Plaintiff Monique D.”
D&G Holdings, LLC v. Sylvia Mathews Burwell, 156 F. Supp. 3d 798 (W.D. La. 2016). “§ 1395ff(b)(l)(A); 42 C.F.R. § 405.1136 ; 42 C.F.R. § 405.1130 ).”
B & H Med., LLC v. United States, 116 Fed. Cl. 671 (Fed. Cl. 2014). “42 C.F.R. § 405.1136 (a). Plaintiff filed exhibits with its complaint that document its completion of the first and second levels of administrative review.”
True Health Diagnostics, LLC v. Azar, 392 F. Supp. 3d 666 (E.D. Tex. 2019). “§ 1395ff(b)(1)(A) ; 42 C.F.R. § 405.1136 ; 42 C.F.R. § 405.1130 .”
Ebert v. Anthem Health Plans of Kentucky, Inc. (W.D. Ky. 2022). · cites it 4× “at 3 (citing 42 C.F.R. § 405.1136 (d)(1), 45 C.F.R. § 4.”
Perot v. United States Dep't of Health & Human Servs., 304 F. App'x 245 (5th Cir. 2008). “42 C.F.R. § 405.1136 (c)(2). The Medicare Appeals Council mailed Perot a final adverse decision on January 27, 2006, making February 1 the presumptive date of receipt.”
United Healthcare Ins. v. Sebelius, 774 F. Supp. 2d 1014 (D. Minnesota 2011). “42 C.F.R. § 405.1136 (d)(1). Additionally, the Commissioner has asserted subrogation rights in the present case under 42 U.”
Show all 32 citing cases →
— 42 C.F.R. § 405.1136(a) — 1 case
Pac. Edge Diagnostics USA, Ltd. v. Kennedy (M.D. Penn. 2025).
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.