C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 422—MEDICARE ADVANTAGE PROGRAM › Subpart M—Grievances, Organization Determinations and Appeals

42 C.F.R. § 422.600

Right to a hearing

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(a) If the amount remaining in controversy after reconsideration meets the threshold requirement established annually by the Secretary, any party to the reconsideration (except the MA organization) who is dissatisfied with the reconsidered determination has a right to a hearing before an ALJ.

(b) The amount remaining in controversy, which can include any combination of Part A and Part B services, is computed in accordance with part 405 of this chapter. For purposes of calculating the amount remaining in controversy under this section, references to coinsurance in § 405.1006(d) of this chapter should be read to include coinsurance and copayment amounts.

(c) If the basis for the appeal is the MA organization's refusal to provide services, CMS uses the projected value of those services to compute the amount remaining in controversy.

[63 FR 35107, June 26, 1998, as amended at 70 FR 4740, Jan. 28, 2005; 86 FR 6102, Jan. 19, 2021]
Notes of Decisions
Cited in 11 cases (5 in the last 5 years), 2006–2025 · leading case: Giesse v. Sec'y of the Dep't of Health & Human Servs., 522 F.3d 697 (6th Cir. 2008).
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Giesse v. Sec'y of the Dep't of Health & Human Servs., 522 F.3d 697 (6th Cir. 2008). · cites it 2× “§ 1395w-22(g)(5); 42 C.F.R. § 422.600 (a). If the enrollee disagrees with the decision of the ALJ, he may request that the MAC review the case.”
Naomi Aylward v. Selecthealth, Inc., 35 F.4th 673 (9th Cir. 2022). “§ 405 (g)); 42 C.F.R. § 422.600 . An enrollee who is dissatisfied with the ALJ’s decision may then seek review by the Medicare Appeals Council.”
Caris MPI v. UnitedHealthcare, 108 F.4th 340 (5th Cir. 2024). “§ 1395w-22(g)(5); 42 C.F.R. § 422.600 . If the enrollee remains dissatisfied, he or she may seek judicial review of the organization determination, but only after the enrollee has completely exhausted his or her administrative remedies under the Medicare Act and its regulations.”
Matthews v. Leavitt, 452 F.3d 145 (2d Cir. 2006). “630 (1998) (repealed); 42 C.F.R. § 422.600 (a) (2006) (currently applicable analogous provision).”
Kaiser Found. Health Plan, Inc. v. Burwell, 147 F. Supp. 3d 897 (N.D. Cal. 2015). “42 C.F.R. § 422.600 . Subsequently, a party may request that the Medicare Appeals Council.”
Rapport v. Leavitt, 564 F. Supp. 2d 186 (W.D.N.Y. 2008). “§ 1395ff(b)(1)(E); 42 C.F.R. § 422.600 ). A party may request review of an ALJ decision by the Medicare Appeals Board (“MAC”) of the HHS Department Appeals Board within sixty (60) days after the date he or she received notice of the hearing decision or dismissal.”
Giesse v. Sec'y of the Dep't of Health & Human Servs., 476 F. Supp. 2d 734 (N.D. Ohio 2006). “at § 1395w-22(g)(5); 42 C.F.R. § 422.600 (a). If the enrollee is dissatisfied with the ALJ’s decision, he or she may request that the Medicare Appeals Council (“MAC”) review the decision.”
Naomi Aylward v. Selecthealth, Inc., 31 F.4th 719 (9th Cir. 2022). “§ 405 (g)); 42 C.F.R. § 422.600 . An enrollee who is dissatisfied with the ALJ’s decision may then seek review by the Medicare Appeals Council.”
Moses v. United Healthcare Corp. (D. Ariz. 2020). “592 , requested a hearing before an administrative law judge (“ALJ”) pursuant 5 to 42 C.F.R. § 422.600 , or requested review of the ALJ’s decision by the Medicare Appeals 6 Council (“Council”) pursuant to 42 C.”
Sarasota Cnty. Pub. Hosp. Bd. v. Blue Cross & Blue Shield of Florida, Inc. (M.D. Fla. 2021). “42 C.F.R. § 422.600 . After the administrative law judge reviews the “organization determination,” the party can request a review before the Medicare Appeals Council.”
Minimally Invasive Surgery Hosp., Inc. v. United HealthCare Servs., Inc. (D. Kan. 2025). “42 C.F.R. § 422.600 (a). Once an ALJ issues a ruling, then any party (including the Medicare Advantage organization) subject to the ruling may request that the Medicare Appeals Council review the decision.”
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