In re LCD Complaint: Emergency and Non-Emergency Ground Ambulance Services (L37697), DAB CR5707 (2020)

DECISION DISMISSING COMPLAINT

The Aggrieved Party, by his spouse, filed correspondence through the mail, dated August 3, 2020, which the Civil Remedies Division (CRD) of the Departmental Appeals Board (DAB) received on August 14, 2020.  Based on the cover letter and a physician statement included with the cover letter, CRD docketed the Aggrieved Party's correspondence as a complaint challenging the validity of a local coverage determination (LCD).  The matter was then assigned to me for adjudication.

The Aggrieved Party's filing included language that suggested he was seeking to appeal the denial of a Medicare claim, instead of challenging an LCD.  The Aggrieved Party indicated:  "I am writing to appeal Medicare's denial of coverage for ambulance services on the night of April 9, 2020."  Further, the Aggrieved Party included with the correspondence a signed and completed form to appeal the denial of the Medicare claim.  This suggested that the Aggrieved Party was seeking to appeal the denial of the claim, either instead of or in addition to challenging the validity of the LCD.

LCDs are policies issued by Medicare fiscal intermediaries or carriers, generally known as contractors.  42 C.F.R. § 426.110 (definition of contractor).  The validity of LCDs may be challenged.  42 U.S.C. § 1395ff(f); 42 C.F.R. pt. 426.  However, if a Medicare beneficiary (or a physician, hospital, or other provider or supplier acting on the beneficiary's behalf) submits a Medicare claim that is denied, the denial may be appealed through a claim appeals process.  42 U.S.C. § 1395ff(a)-(d).  The review of the validity of

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an LCD and the review of a denial of a Medicare claim are distinct from each other.  42 C.F.R. §§ 405.1062(c), 426.310(a).  As an administrative law judge with the DAB, I have jurisdiction to review challenges to LCDs, but I do not have authority to order the payment of a denied Medicare claim.  42 C.F.R. §§ 426.450(a), 426.455(b).

In order the ensure that the Aggrieved Party's right to appeal the claim denial was not prejudiced, I requested CRD staff to make contact and explain that the process for appealing the denial of a Medicare claim is completely separate and independent of the process for challenging an LCD.  Subsequently, in a letter dated August 19, 2020, and received on August 28, 2020, the Aggrieved Party requested to withdraw the complaint.

I am authorized to issue a decision dismissing a complaint when the Aggrieved Party withdraws a complaint before I issue a decision regarding the LCD.  42 C.F.R. §§ 426.423(a), (c)(1), 426.444(b)(7), 426.450(a)(3).  Accordingly, I order that the complaint be dismissed.  The Aggrieved Party may not file another complaint challenging the same LCD for six months.  42 C.F.R. § 426.423(c)(1).

As mentioned above, the Aggrieved Party submitted what appears to be the original copy of the Medicare Summary Notice (MSN) denying his claim.  The MSN includes a form and instructions for filing an appeal of the claim denial.  Because the correspondence and its attachments appear to have been misfiled with CRD, the original copy of the MSN will be returned to the Aggrieved Party along with this decision (a copy of the MSN will remain in the electronic record of this case).  If the Aggrieved Party wants to appeal the denial of the Medicare claim, the Aggrieved Party should, as soon as possible, send the appeal to the address shown on the MSN.