GroundRules
42 CFR 426.431: ALJ's review of the LCD to apply the reasonableness standard.
Where this section sits in the code
- Title 42—Public Health
- 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 D—Review of an LCD
(a) Required steps. To review the provision(s) listed in the aggrieved party's complaint based on the reasonableness standard, an ALJ must:
(1) Confine the LCD review to the provision(s) of the LCD raised in the aggrieved party's complaint.
(2) Conduct a hearing, unless the matter can be decided on the written record.
(3) Close the LCD review record to the taking of evidence.
(4) Treat as precedential any previous Board decision under § 426.482 that involves the same LCD provison(s), same specific issue and facts in question, and the same clinical conditions.
(5) Issue a decision as described in § 426.447.
(b) Optional steps. The ALJ may do the following to apply the reasonableness standard to the provision(s) listed in the aggrieved party's complaint:
(1) Consult with appropriate scientific or clinical experts concerning evidence.
(2) Consider any previous ALJ decision made under § 426.447 regarding the same provision(s) of the LCD under review and for the same clinical conditions.
(c) Authority for ALJs in LCD reviews when applying the reasonableness standard. In applying the reasonableness standard to a provision (or provisions) of an LCD, the ALJ must follow all applicable laws, regulations, rulings, and NCDs.
Collected 2026-08-27T02:26:11Z. Source file · JSON