Department of Health and Human Services
DEPARTMENTAL APPEALS BOARD
Civil Remedies Division
In re LCD Complaint:
Pressure Reducing Support Surfaces – Group 1 (LCD No. L33830)
Docket No. C-24-371
Decision No. CR6463
DECISION DISMISSING COMPLAINT
In an acknowledgment and order dated April 8, 2024, the Civil Remedies Division of the Departmental Appeals Board acknowledged that it had received correspondence, dated March 27, 2024, from an aggrieved party. The aggrieved party complained that the Medicare Administrative Contractor had denied her claim for a “Pressure Reducing Support Service” and said that she wrote “to challenge the Local Coverage Determination.”
We therefore treated this submission as a challenge to a local coverage determination (LCD), LCD ID L33830, which addresses Medicare coverage for Pressure Reducing Support Surfaces – Group 1.
In the April 8 acknowledgment, I explained that the regulations governing these proceedings do not allow me to accept an incomplete complaint and that I had determined that her complaint did not meet regulatory requirements. 42 C.F.R. §§ 426.400(c), 426.410(b)(1) and (2). Pursuant to 42 C.F.R. § 426.410(c)(1), I offered the aggrieved party an opportunity to file an acceptable complaint and directed her to do so no later than May 8, 2024. I advised her that her amended complaint should include the following information:
1. Beneficiary identifying information:
(i) Name
(ii) Mailing Address
(iii) State of residence, if
different from mailing address (iv) Telephone number
(v) Health Insurance Claim number, if applicable
Page 2
(vi) Email address, if applicable.
2. If the beneficiary has a representative, representative identifying information, which must include the representative’s name, mailing address, telephone number, email address, if any, and a copy of the written authorization to represent the beneficiary.
3. Treating Physician Written Statement. A copy of a written statement from the treating physician that the beneficiary needs the service that is the subject of the LCD. This statement may be in the form of a written order for the service or other documentation from the beneficiary’s medical record (such as progress notes or discharge summary) indicating that the beneficiary needs the service.
4. LCD identifying information.
(i) Name of the contractor using the LCD.
(ii) Title of the LCD being challenged.
(iii) The specific provision (or provisions) of the LCD adversely affecting the aggrieved party.
5. Aggrieved party statement. A statement from the aggrieved party explaining what service is needed and why the aggrieved party thinks that the provision(s) of the LCD is (are) not valid under the reasonableness standard.
6. Clinical or scientific evidence. Copies of clinical or scientific evidence that support the complaint and an explanation for why the aggrieved party thinks that this evidence shows that the LCD is not reasonable.
In e-mail correspondence dated April 15, 2024, the aggrieved party’s representative responded and asked that the aggrieved party’s case be closed. On April 16, 2024, the Civil Remedies Division received the aggrieved party’s email correspondence and filed it in the electronic case record.
An aggrieved party may withdraw its complaint regarding an LCD challenge upon written withdrawal notice to the administrative law judge and Medicare contractor. 42 C.F.R. § 426.423(b). Upon receiving a withdrawal notice from an aggrieved party, the administrative law judge “issues a decision dismissing the complaint under § 426.444 and informs the aggrieved party that he or she may not file another complaint to the same coverage determination for 6 months.” 42 C.F.R. § 426.423(c)(1).
Page 3
I therefore issue this decision dismissing the aggrieved party’s complaint. 42 C.F.R. § 426.444(b)(7). The aggrieved party may not file another complaint concerning the same coverage determination for six months from the date of this decision. 42 C.F.R. § 426.423(a).
Carolyn Cozad Hughes Administrative Law Judge