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. § 405.900

Basis and scope

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(a) Statutory basis. This subpart is based on the following provisions of the Act:

(1) Section 1869(a) through (e) and (g) of the Act.

(2) Section 1862(b)(2)(B)(viii) of the Act.

(b) Scope. This subpart establishes the requirements for appeals of initial determinations for benefits under Part A or Part B of Medicare, including the following:

(1) The initial determination of whether an individual is entitled to benefits under Part A or Part B. (Regulations governing reconsiderations of these initial determinations are at 20 CFR, part 404, subpart J).

(2) The initial determination of the amount of benefits available to an individual under Part A or Part B.

(3) Any other initial determination relating to a claim for benefits under Part A or Part B, including an initial determination made by a quality improvement organization under section 1154(a)(2) of the Act or by an entity under contract with the Secretary (other than a contract under section 1852 of the Act) to administer provisions of titles XVIII or XI of the Act.

[70 FR 11472, Mar. 8, 2005, as amended at 80 FR 10617, Feb. 27, 2015]
Notes of Decisions
Cited in 10 cases (5 in the last 5 years), 2012–2025 · leading case: California Clinical Lab'y Ass'n v. Sec'y of Dep't of Health & Human Servs., 104 F. Supp. 3d 66 (D.D.C. 2015).
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California Clinical Lab'y Ass'n v. Sec'y of Dep't of Health & Human Servs., 104 F. Supp. 3d 66 (D.D.C. 2015). “§§ 1395ff(b)-(e); see also 42 C.F.R. § 405.900 et seq. That process ordinarily entails administrative requests for reconsideration, a hearing before an administrative law judge (“ALJ”), and, if desired, review by the Departmental Appeals Board (“DAB”).”
Ocean Harbor Cas. Ins. v. MSPA Claims, 1, 261 So. 3d 637 (Fla. 3d DCA 2018). “42 C.F.R. § 405.900 ("This subpart establishes the requirements for appeals of initial determinations for benefits under Part A or Part B of Medicare.”
Steven Hartpence v. Kinetic Concepts, Inc., 44 F.4th 838 (9th Cir. 2022). “See 42 C.F.R. § 405.900 et seq. That process includes a hearing before an Administrative Law Judge (“ALJ”), see id.”
Greenwald v. Price, No. 2017-0797 (D.D.C. June 7, 2022). “at § 1395ff(b)– (e); 42 C.F.R. §§ 405.900 et seq. Neither the ALJ nor the DAB is bound by the LCD, but they cannot invalidate or set aside the LCD in its entirety.”
Ocean Harbor Cas. Ins. v. MSPA Claims, 1, 261 So. 3d 637 (Fla. 3d DCA 2018). “42 C.F.R. § 405.900 ("This subpart establishes the requirements for appeals of initial determinations for benefits under Part A or Part B of Medicare.”
Dynasty Healthcare, LLC v. Nat'l Gov't Servs., Inc., No. 21-1622 (2d Cir. July 7, 2023). “§§ 405 (g)-(h), 1395ff(b)(1)(A) 11 (applying § 405(g)-(h) to the Medicare Act); 42 C.F.R. § 405.900 et seq. As 12 relevant here, for example, a provider could seek administrative review of a 13 MAC’s determination that the provider was overpaid, see 42 C.”
THDL Liquidating LLC v. Azar, II, No. 19-50280 (Bankr. D. Del. Aug. 29, 2019). “§ 1395ff and 42 C.F.R. § 405.900 et seq. Defendants are precluded from recouping overpayments until a The Third Circuit addressed this very issue extensively in University Medical Center, where it stated, in agreement with the Ninth Circuit, that “where there is an independent…”
Capital Hospice v. Becerra, No. 1:23-cv-01741 (E.D. Va. Mar. 31, 2025). “§ 1395ff; 42 C.F.R. §§ 405.900 to 1140. The appeals process consists of: (1) requesting a redetermination of the decision by the Medicare contractor who issued the denial, 42 U.”
Pac. Edge Diagnostics USA, Ltd. v. Kennedy, No. 1:25-cv-00291 (M.D. Pa. Apr. 23, 2025). “§§ 1395ff(b)–(d); 42 C.F.R. § 405.900 et seq. First, a dissatisfied person or entity can seek a redetermination.”
United Med. Healthcare, Inc. v. Dep't of Health & Human Servs., 889 F. Supp. 2d 832 (E.D. La. 2012). “See 42 C.F.R. § 405.900 , et seq. Subsequent to the contractor or CMS making an initial determination of overpayment, a beneficiary or provider may ask for a redetermination by that same contractor.”
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