local coverage determination

(2) Local coverage determination (A) In general Review of any local coverage determination shall be subject to the following limitations: (i) Upon the filing of a complaint by an aggrieved party, such a determination shall be reviewed by an administrative law judge. The administrative law judge— (I) shall review the record and shall permit discovery and the taking of evidence to evaluate the reasonableness of the determination, if the administrative law judge 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. (ii) Upon the filing of a complaint by an aggrieved party, a decision of an administrative law judge under clause (i) shall be reviewed by the Departmental Appeals Board of the Department of Health and Human Services. (iii) The Secretary shall implement a decision of the administrative law judge or the Departmental Appeals Board within 30 days of receipt of such decision. (iv) A decision of the Departmental Appeals Board constitutes a final agency action and is subject to judicial review. (B) Definition of local coverage determination For purposes of this section, the term “local coverage determination” means a determination by a fiscal intermediary or a carrier under part A or part B, as applicable, respecting whether or not a particular item or service is covered on an intermediary- or carrier-wide basis under such parts, in accordance with section 1395y(a)(1)(A) of this title . (C) Local coverage determinations for clinical diagnostic laboratory tests For provisions relating to local coverage determinations for clinical diagnostic laboratory tests, see section 1395m–1(g) of this title .


42 USC § 1395ff(f)(2)

Scoping language

For purposes of this section
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