Department of Health and Human Services DEPARTMENTAL APPEALS BOARD Civil Remedies Division |
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IN THE CASE OF | |
In re CMS LCD Complaint: Positron Emission Tomography Scan |
DATE: October 18, 2006 |
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Docket No. C-06-579 Decision No. CR1521 |
DECISION | |
DECISION DISMISSING CASE The July 3, 2006 complaint in this matter was filed
by Robert C. Quackenbush, M.D., a treating physician for the complainant.
In it, Dr. Quackenbush asks to appeal the Local Coverage Determination
(LCD) denial
of a Positron Emission Tomography (PET) scan for the complainant made
by Mutual of Omaha, which Dr. Quackenbush identifies as the complainant’s
Medicare carrier.
On
August 21, 2006, I directed that a letter be sent to Dr. Quackenbush
and the complainant
explaining that Dr. Quackenbush’s letter of July 3, 2006 was
not an “acceptable” complaint challenging a LCD.
The July 3, 2006 letter was not acceptable because Dr. Quackenbush
did not meet the definition of an aggrieved party or his representative.
42 C.F.R. § 426.110. Also, the July 3, 2006 letter did not meet
the criteria set out at 42
C.F.R. §§ 426.410(b)(1) and (2), which sections in turn
adopt detailed content and timeliness requirements for complaints
set out in 42 C.F.R. For the reasons explained below, I find that the complaint is not acceptable as a complaint challenging a LCD. In my August 21, 2006 letter, I directed Dr. Quackenbush and the complainant that the July 3, 2006 letter would have to be amended. My August 21, 2006 letter informed Dr. Quackenbush and the complainant what information was required in order to file an acceptable complaint to challenge an LCD. The letter also stated that, if there was no response by September 21, 2006, the regulations require that I issue a mandatory dismissal of any complaint not successfully amended. The letter stated that “. . . the ALJ [Administrative Law Judge] must issue a decision dismissing the unacceptable complaint.” 42 C.F.R. § 426.410(c)(2) (emphasis added). As of the date of this decision, I have received no response from either Dr. Quackenbush or the complainant, nor any other person that meets the definition of an aggrieved party. Assuming the person filing the July 3, 2006 letter intended that letter to be an LCD complaint, it is unacceptable because the person filing the July 3,2006 letter was not an aggrieved party or his representative. Further, the July 3, 2006 letter did not contain the information specified at 42 C.F.R. § 426.400(c)(1), (4), (5), and (6). I have afforded both Dr. Quackenbush and the complainant the opportunity to amend the complaint, as required by 42 C.F.R. § 426.410(c)(1). The person meeting the definition of an aggrieved party or his representative has failed to submit an acceptable complaint within the timeframe I have established. Therefore, pursuant to 42 C.F.R. § 426.410(c)(2), I must issue a decision dismissing the complaint. The regulations require that an ALJ’s decision contain certain provisions. 42 C.F.R. § 426.450. Pursuant to 42 C.F.R. § 426.450(a), my decision must include findings. Therefore, as required by 42 C.F.R. § 426.450(a)(3), I find that the aggrieved party or his representative has failed to file an acceptable complaint challenging an LCD. Accordingly, for the reasons set forth above, I decide that this case must be dismissed. The regulations, at 42 C.F.R. § 426.450(b), require that an ALJ’s decision contain certain other information. This decision contains the information required by 42 C.F.R. § 426.450(b)(1), (2), and (6). Because I am dismissing this case for failure to file an acceptable complaint, the information required by 42 C.F.R. § 426.450(b)(3), (4), and (5) is not a part of the record before me and is not included for that reason. The aggrieved party or his representative has 30 days from the date of this Decision to file an appeal with the Departmental Appeals Board, in accordance with 42 C.F.R. § 426.465. |
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JUDGE | |
José A. Anglada Administrative Law Judge |
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