national coverage determination

(1) National coverage determinations (A) In general Review of any national coverage determination shall be subject to the following limitations: (i) Such a determination shall not be reviewed by any administrative law judge. (ii) Such a determination shall not be held unlawful or set aside on the ground that a requirement of section 553 of title 5 or section 1395hh(b) of this title , relating to publication in the Federal Register or opportunity for public comment, was not satisfied. (iii) Upon the filing of a complaint by an aggrieved party, such a determination shall be reviewed by the Departmental Appeals Board of the Department of Health and Human Services. In conducting such a review, the Departmental Appeals Board— (I) shall review the record and shall permit discovery and the taking of evidence to evaluate the reasonableness of the determination, if the Board determines that the record is incomplete or lacks adequate information to support the validity of the determination; (II) may, as appropriate, consult with appropriate scientific and clinical experts; and (III) shall defer only to the reasonable findings of fact, reasonable interpretations of law, and reasonable applications of fact to law by the Secretary. (iv) The Secretary shall implement a decision of the Departmental Appeals Board within 30 days of receipt of such decision. (v) A decision of the Departmental Appeals Board constitutes a final agency action and is subject to judicial review. (B) Definition of national coverage determination For purposes of this section, the term “national coverage determination” means a determination by the Secretary with respect to whether or not a particular item or service is covered nationally under this subchapter, but does not include a determination of what code, if any, is assigned to a particular item or service covered under this subchapter or a determination with respect to the amount of payment made for a particular item or service so covered.


42 USC § 1395ff(f)(1)

Scoping language

For purposes of this section
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