42 C.F.R. § 405.920
Initial determinations
After a claim is filed with the appropriate contractor in the manner and form described in subpart C of part 424 of this chapter, the contractor must—
(a) Determine if the items and services furnished are covered or otherwise reimbursable under title XVIII of the Act;
(b) Determine any amounts payable and make payment accordingly; and
(c) Notify the parties to the initial determination of the determination in accordance with § 405.921.
Notes of Decisions
Cited in 27
cases (14 in the last 5 years), 2010–2026 · leading case: Arturo Porzecanski v. Alex Azar, 943 F.3d 472 (D.C. Cir. 2019).
Arturo Porzecanski v. Alex Azar, 943 F.3d 472 (D.C. Cir. 2019). “” 42 C.F.R. § 405.920 . Initial coverage determinations are made by contractors HHS hires to manage the preliminary claims administration process in designated geographic areas.”
Maxmed Healthcare, Inc. v. Thomas Price, 860 F.3d 335 (5th Cir. 2017). “See 42 C.F.R. § 405.920 . A provider who is displeased with the Medicare Administrative Contractor’s initial determination may then seek a “redetermination”—the first step in a five-step appeal process.”
Global Rescue Jets, LLC v. Kaiser Found. Health Plan, 30 F.4th 905 (9th Cir. 2022). “Before filing suit in court, a Medicare beneficiary must proceed through five levels of administrative review, described in regulations issued by CMS as follows: (1) an initial determination by the medicare administrative contractor, 42 C.F.R. § 405.920 ; (2) a redetermination…”
Anniken Prosser v. Xavier Becerra, 2 F.4th 708 (7th Cir. 2021). “See 42 C.F.R. § 405.920 (a). Contractors may issue a local coverage determination that categorically de- cides whether a treatment is covered, a determination that be- comes binding on the issuing contractor for future claims.”
Int'l Rehabilitative Sciences Inc. v. Sebelius, 688 F.3d 994 (9th Cir. 2012). “If the supplier is dissatisfied with the redetermination, it may have a qualified independent contractor reconsider the claim.”
Edwin R. Banks v. Sec'y, Dep't of Health & Human Servs., 38 F.4th 86 (11th Cir. 2022). “§ 1395ff(a); 42 C.F.R. § 405.920 . Second, if the beneficiary is dissatisfied with the initial determination, he may request a “re- determination” by the contractor.”
Palomar Med. Ctr. v. Kathleen Sebelius, 693 F.3d 1151 (9th Cir. 2012). “§ 1395ff(a); 42 C.F.R. § 405.920 . Initial determinations are appealable.”
Art of Healing Med., P.C. v. Burwell, 91 F. Supp. 3d 400 (E.D.N.Y 2015). “§ 1395ff(a)(l); 42 C.F.R. §§ 405.920 , 405.921. This “initial determination” notice indicates whether there is coverage and, if so, the amount payable.”
Porzecanski v. Azar, 316 F. Supp. 3d 11 (D.C. Cir. 2018). “42 C.F.R. §§ 405.920 , 405.924(b). The initial contractor may review the claim individually, or the contractor may deny the claim automatically by relying on a "local coverage determination," which is a decision promulgated by the contractor "to provide guidance to the public…”
Gentiva Healthcare Corp. v. Sebelius, 857 F. Supp. 2d 1 (D.D.C. 2012). “Consistent with Medicare regulations governing the appeals process, see 42 C.F.R. §§ 405.920 , 405.924(b), 405.940-58, Gentiva first sought a redetermination from Cahaba and then sought reconsideration by another Medicare contractor.”
Morton Plant Hosp. Ass'n, Inc. v. Sebelius, 747 F. Supp. 2d 1349 (M.D. Fla. 2010). “§ 1395ff(a); 42 C.F.R. §§ 405.920 , 405.924. If a provider is not satisfied with the Intermediary’s initial determination, that provider may request a “redetermination” from the Intermediary.”
Int'l Rehabilitative Sciences, Inc. v. Sebelius, 737 F. Supp. 2d 1281 (W.D. Wash. 2010). “§ 1395ff(a)-(c); 42 C.F.R. §§ 405.920 , .940, .960, .1002.”
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