42 C.F.R. § 422.612
Judicial review
(a) Review of ALJ's or attorney adjudicator's decision. Any party, including the MA organization, may request judicial review (upon notifying the other parties) of an ALJ's or attorney adjudicator's decision if—
(1) The Council denied the party's request for review; and
(2) The amount in controversy meets the threshold requirement established annually by the Secretary.
(b) Review of Council decision. Any party, including the MA organization, may request judicial review (upon notifying the other parties) of the Council decision if it is the final decision of CMS and the amount in controversy meets the threshold established in paragraph (a)(2) of this section.
(c) How to request judicial review. In order to request judicial review, a party must file a civil action in a district court of the United States in accordance with section 205(g) of the Act. See part 405 of this chapter for a description of the procedures to follow in requesting judicial review.
Notes of Decisions
Cited in 17
cases (7 in the last 5 years), 2005–2026 · leading case: Giesse v. Sec'y of the Dep't of Health & Human Servs., 522 F.3d 697 (6th Cir. 2008).
Giesse v. Sec'y of the Dep't of Health & Human Servs., 522 F.3d 697 (6th Cir. 2008). “§ 1395w-22(g)(5); 42 C.F.R. § 422.612 . The Medicare Act’s grant of subject matter jurisdiction only permits judicial review of “the final decision of [the Secretary] made after a hearing.”
Global Rescue Jets, LLC v. Kaiser Found. Health Plan, 30 F.4th 905 (9th Cir. 2022). “§ 1395w-22(g)(5); 42 C.F.R. § 422.612 . 3 The statutory provision establishing this review scheme, 42 U.”
Am. Chiropractic Ass'n v. Leavitt, 431 F.3d 812 (D.C. Cir. 2005). “§ 1395w-22(g)(5); 42 C.F.R. § 422.612 (a), (c). The chiropractor who provided the service could also mount an administrative challenge by “waivfing] any right to payment from the enrollee” and becoming the enrollee’s assignee.”
Naomi Aylward v. Selecthealth, Inc., 35 F.4th 673 (9th Cir. 2022). “§ 1395w- 22(g)(5); 42 C.F.R. § 422.612 . The familiar requirement that claimants must exhaust their administrative remedies before seeking judicial review of social security or disability benefits determinations rests on § 205(h) of Title II of the SSA, which makes the judicial…”
Assocs. Rehab. Recovery, Inc. v. Humana Med. Plan, Inc., 76 F. Supp. 3d 1388 (S.D. Fla. 2014). “42 C.F.R. § 422.612 (a) (2014). As the Court finds that dismissal without prejudice is appropriate in order to allow Plaintiff -to pursue its administrative remedies, the Court declines to address Defendant’s alternative arguments that dismissal is appropriate because Plaintiffs…”
Haaland v. Presbyterian Health Plan, Inc., 292 F. Supp. 3d 1222 (D.N.M. 2018). “Here, Plaintiffs insist that they are not complaining about the denial of Medicare benefits but are, rather, seeking damages "due to PHP's medical negligence and profit-motivated denial of benefits that led to [Ms. Hall's] wrongful death.”
Doctors Med. Ctr. of Modesto, Inc. v. Kaiser Found. Health Plan, Inc., 989 F. Supp. 2d 1009 (E.D. Cal. 2013). “§ 1395w-22(g)(5); 42 C.F.R. § 422.612 (c). With respect to its remaining state common law claims for open book account and account stated, the Hospital argues that those claims do not “arise under” the Medicare Act and are therefore not subject to its exhaustion requirements.”
Rapport v. Leavitt, 564 F. Supp. 2d 186 (W.D.N.Y. 2008). “§ 1395ff (b)(1)(E), 42 C.F.R. § 422.612 (a) and (b)). BACKGROUND On December 5, 2006, plaintiff, then ninety (90) years old, was admitted to Highland Hospital (“Highland”) in Rochester, N.”
Tenet Healthsystem GB, Inc. v. Care Improvement Plus South Cent. Ins., 162 F. Supp. 3d 1307 (N.D. Ga. 2016). “§ 1395w-22(g)(5); 42 C.F.R. § 422.612 (c). The Eleventh Circuit has recognized that a lawsuit that seeks to recover on any claim “arising under” the Medicare Act must first be brought through the HHS administrative appeals process before it can be taken to federal court.”
Giesse v. Sec'y of the Dep't of Health & Human Servs., 476 F. Supp. 2d 734 (N.D. Ohio 2006). “§ 1395w-22(g)(5); 42 C.F.R. § 422.612 . The Secretary has adopted an administrative review process that distinguishes between “grievances” and challenges to an “organization determination.”
Naomi Aylward v. Selecthealth, Inc., 31 F.4th 719 (9th Cir. 2022). “§ 1395w- 22(g)(5); 42 C.F.R. § 422.612 . The familiar requirement that claimants must exhaust their administrative remedies before seeking judicial review of social security or disability benefits determinations rests on § 205(h) of Title II of the SSA, which makes the judicial…”
John Kodenkandeth v. UPMC Health Plan Inc (3rd Cir. 2026). “562 (b), an enrollee may seek judicial review “in a district court of the United States” if “[t]he amount in controversy meets the threshold requirement,” 42 C.F.R. § 422.612 ; 42 U.S.C. §§ 1395w-22(g)(5), 405(g).”
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