C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 426—REVIEW OF NATIONAL COVERAGE DETERMINATIONS AND LOCAL COVERAGE DETERMINATIONS › Subpart C—General Provisions for the Review of LCDs and NCDs

42 C.F.R. § 426.325

What may be challenged

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(a) Only LCDs or NCDs (including deemed NCDs) that are currently effective may be challenged.

(b) Some items are not reviewable under this part, including the following:

(1) Pre-decisional materials, including—

(i) Draft LCDs;

(ii) Template LCDs or suggested LCDs; and

(iii) Draft NCDs, including national coverage decision memoranda.

(2) Retired LCDs or withdrawn NCDs.

(3) LCD or NCD provisions that are no longer in effect due to revisions or reconsiderations.

(4) Interpretive policies that are not an LCD or NCD.

(5) Contractor decisions that are not based on section 1862(a)(1)(A) of the Act.

(6) Contractor claims processing edits.

(7) Payment amounts or methodologies.

(8) Procedure coding issues, including determinations, methodologies, definitions, or provisions.

(9) Contractor bulletin articles, educational materials, or Web site frequently asked questions.

(10) Any M + C organization or managed care plan policy, rule, or procedure.

(11) An individual claim determination.

(12) Any other policy that is not an LCD or an NCD as set forth in § 400.202 of this chapter.

Notes of Decisions
Cited in 1 case, 2008–2008 · leading case: Bailey v. Mut. of Omaha Ins., 534 F. Supp. 2d 43 (D.D.C. 2008).
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Bailey v. Mut. of Omaha Ins., 534 F. Supp. 2d 43 (D.D.C. 2008). · cites it 2× “at 1-2); see 42 C.F.R. § 426.325 (a), (b)(2). The ALJ was required to dismiss the complaint and inform plaintiff that she would receive individual claim review without application of the retired LCD.”
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