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. § 405.968

Conduct of a reconsideration

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(a) General rules. (1) A reconsideration consists of an independent, on-the-record review of an initial determination, including the redetermination and all issues related to payment of the claim. In conducting a reconsideration, the QIC reviews the evidence and findings upon which the initial determination, including the redetermination, was based, and any additional evidence the parties submit or that the QIC obtains on its own. If the initial determination involves a finding on whether an item or service is reasonable and necessary for the diagnosis or treatment of illness or injury (under section 1862(a)(1)(A) of the Act), a QIC's reconsideration must involve consideration by a panel of physicians or other appropriate health care professionals, and be based on clinical experience, the patient's medical records, and medical, technical, and scientific evidence of record to the extent applicable.

(b) Authority of the QIC. (1) National coverage determinations (NCDs), CMS Rulings, Council decisions designated by the Chair of the Departmental Appeals Board as having precedential effect under § 401.109 of this chapter, and applicable laws and regulations are binding on the QIC.

(2) QICs are not bound by LCDs, LMRPs, or CMS program guidance, such as program memoranda and manual instructions, but give substantial deference to these policies if they are applicable to a particular case. A QIC may decline to follow a policy, if the QIC determines, either at a party's request or at its own discretion, that the policy does not apply to the facts of the particular case.

(3) If a QIC declines to follow a policy in a particular case, the QIC's reconsideration explains the reasons why the policy was not followed.

(4) A QIC's decision to decline to follow a policy under this section applies only to the specific claim being reconsidered and does not have precedential effect.

(5) A QIC may raise and develop new issues that are relevant to the claims in a particular case provided that the contractor rendered a redetermination with respect to the claims.

(c) Qualifications of the QIC's panel members. (1) Members of a QIC's panel who conduct reconsiderations must have sufficient medical, legal, and other expertise, including knowledge of the Medicare program.

(2) When a redetermination is made with respect to whether an item or service is reasonable and necessary (section 1862(a)(1)(A) of the Act), the QIC designates a panel of physicians or other appropriate health care professionals to consider the facts and circumstances of the redetermination.

(3) Where a claim pertains to the furnishing of treatment by a physician, or the provision of items or services by a physician, a reviewing professional must be a physician.

(d) Disqualification of a QIC panel member. No physician or health care professional employed by or otherwise working for a QIC may review determinations regarding—

(1) Health care services furnished to a patient if that physician or health care professional was directly responsible for furnishing those services; or

(2) Health care services provided in or by an institution, organization, or agency, if that physician or health care professional or any member of the physician's family or health care professional's family has, directly or indirectly, a significant financial interest in that institution, organization, or agency (see the term family member as defined in § 405.902).

[70 FR 11472, Mar. 8, 2005, as amended at 82 FR 5107, Jan. 17, 2017]
Notes of Decisions
Cited in 17 cases (7 in the last 5 years), 2009–2025 · leading case: United States Ex Rel. Zizic v. Q2Administrators, LLC, 728 F.3d 228 (3rd Cir. 2013).
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United States Ex Rel. Zizic v. Q2Administrators, LLC, 728 F.3d 228 (3rd Cir. 2013). · cites it 3× “” 42 C.F.R. § 405.968 (c)(3). The QIC’s decision with respect to whether the DME is medically reasonable and necessary must “be based on applicable information, including clinical experience (including the medical records of the individual involved) and medical, technical, and…”
Cumberland Cnty. Hosp. Sys., Inc. v. Burwell, 816 F.3d 48 (4th Cir. 2016). · cites it 2× “” 42 C.F.R. § 405.968 (a)(1). At the third step, the healthcare provider may challenge the QIC’s decision by requesting a hearing before an ALJ.”
Almy v. Sebelius, 679 F.3d 297 (4th Cir. 2012). “” 42 C.F.R. § 405.968 (a)(1). BioniCare is correct that such input was required, both because “the initial determination involve[d] a finding on whether an item or service is reasonable and necessary,” id.”
Almy v. Sebelius, 749 F. Supp. 2d 315 (D. Maryland 2010). · cites it 2× “42 C.F.R. §§ 405.968 (a)(1) and (c)(3). The QIC’s “reconsideration,” which is non-precedential, may be further appealed to an Administrative Law Judge (“ALJ”).”
Am. Hosp. Ass'n v. Sebelius, 76 F. Supp. 3d 43 (D.D.C. 2014). “” 42 C.F.R. § 405.968 (a). The QIC also has 60 days to resolve claims.”
Willowood of Great Barrington, Inc. v. Sebelius, 638 F. Supp. 2d 98 (D. Mass. 2009). “§ 1395ff(c)(3)(B)(i) and 42 C.F.R. § 405.968 . If the claimant remains dissatisfied with the decision and the amount in controversy exceeds a certain threshold amount, the claimant may request a hearing before an ALJ.”
Cgi Fed. Inc. v. United States, 118 Fed. Cl. 337 (Fed. Cl. 2014). “42 C.F.R. § 405.968 (a)(1). QICs must process the provider’s appeal within 60 days.”
Exec. Dir. of the Off. of Vermont Health Access v. Sebelius, 698 F. Supp. 2d 436 (D. Vt. 2010). “§ 1395ff(c)(3)(B)(i); 42 C.F.R. § 405.968 . If the claimant is dissatisfied with the decision of the QIC, and the amount in controversy exceeds a certain threshold amount, the claimant may request a hearing before an ALJ.”
Integrity Soc. Work Servs., LCSW, LLC v. AZAR (E.D.N.Y 2021). · cites it 3× “” 42 C.F.R. § 405.968 . Reconsideration must be completed within 60 calendar days unless an exception applies.”
Oxenberg v. Azar (E.D. Pa. 2021). · cites it 3× “7 42 C.F.R. § 405.968 (c)(1); see also 42 U.”
Russell v. Sebelius, 686 F. Supp. 2d 386 (D. Vt. 2010). “§ 1395ff(c)(3)(B)(i); 42 C.F.R. § 405.968 . If the claimant is dissatisfied with the decision of the QIC, and the amount in controversy exceeds a certain threshold amount, the claimant may request a hearing before an ALJ.”
Robert Odell, Jr. v. Hhs (9th Cir. 2021). “§ 1395ff(c), (c)(3)(B)(ii)(II); 42 C.F.R. § 405.968 (b)(2). Third, a party can seek a hearing before an administrative law judge.”
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