In re LCD Complaint: Ambulance Services (Ground Ambulance), DAB CR5919 (2021)

DECISION DISMISSING UNACCEPTABLE COMPLAINT

Jane A. Palmer (the Aggrieved Party) submitted correspondence which the Civil Remedies Division treated as a challenge to a local coverage determination (LCD) and docketed as C‑21‑816.  I was designated to review the purported LCD challenge.

The applicable regulations require that I first determine whether an aggrieved party filed an “acceptable” and “valid” complaint.  42 C.F.R. § 426.410(b).  Having reviewed the Aggrieved Party’s initial filings, I determined her complaint was not acceptable under the applicable regulations, and otherwise appeared to be untimely.  Therefore, on June 9, 2021, I issued an Acknowledgment of Receipt and Order to Aggrieved Party to Amend Unacceptable Complaint (Order) in which I informed the Aggrieved Party she had one opportunity to submit an acceptable complaint.  See 42 C.F.R. § 426.410(c)(1).

That Order described the elements required to be included in an LCD complaint to make it acceptable.  I specifically directed the Aggrieved Party to provide the following information: 

• Beneficiary identifying information:  The Aggrieved Party’s letter and the Medicare Explanation of Benefits she submitted with it contained her name, address, and Health Insurance Claim Number, but not her telephone number or e-mail address.  I directed the Aggrieved Party to submit this information.
• Treating Physician Written Statement:  The Aggrieved Party’s initial complaint was unacceptable because it did not include a written statement from a treating physician opining that she required the service that is the subject of the LCD.  I directed the Aggrieved Party to provide such a statement. 

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• LCD-identifying information:  The Aggrieved Party did not identify an LCD in her complaint or state that she was challenging an LCD, but the Medicare Explanation of Benefits accompanying her letter indicated that LCD L35612 was applied to deny her claim.  However, the Aggrieved Party’s initial complaint remained unacceptable because she did not submit the name of the Medicare administrative contractor that applied the LCD or the specific provision (or provisions) of the LCD adversely affecting her.  I directed the Aggrieved Party to submit this information.
• Aggrieved Party statement:  The Aggrieved Party’s initial complaint failed to include a written statement explaining what service is needed and why she believes the LCD provision(s) is (are) invalid under the reasonableness standard.  I directed the Aggrieved Party to provide such a written statement.
• Clinical or scientific evidence:  The Aggrieved Party did not provide copies of clinical or scientific evidence in support of her complaint that could show the LCD is not reasonable.  I directed the Aggrieved Party to submit such evidence and explanation.

In addition to providing the missing information described above, I also directed the Aggrieved Party to submit any additional documentation necessary to address the apparent untimeliness of her complaint.

My June 9, 2021 Order directed the Aggrieved Party to file an amended complaint correcting these identified deficiencies by July 14, 2021.  I advised the Aggrieved Party that if she did not submit an acceptable amended complaint by that time, I would issue a decision dismissing this action.  42 C.F.R. § 426.410(c)(2).

The Aggrieved Party has not filed a response.  Her May 22, 2021 initial complaint therefore remains unacceptable under 42 C.F.R. § 426.410(b).  I am required to dismiss an unacceptable complaint after giving an aggrieved party the opportunity to amend it.  42 C.F.R. § 426.410(c)(2).  Accordingly, I order this complaint dismissed.