Chigurupati Ramana, M.D., DAB CR6732 (2025)

DECISION

Petitioner, Chigurupati Ramana, M.D., is a medical doctor, who had his enrollment in Medicare revoked in Oklahoma, Ohio and Georgia pursuant to 42 C.F.R. § 424.535(a)(12).  Petitioner applied to enroll in the Medicare program in California but, because of his Oklahoma license revocation and Oklahoma Medicaid termination, the Centers for Medicare & Medicaid Services (CMS) denied his application, citing 42 C.F.R. § 424.530(a)(14).  CMS also added Petitioner to the Medicare preclusion list for five years.

Petitioner appeals.

I affirm CMS’s determination.  I find that CMS is authorized to revoke Petitioner’s Medicare enrollment, to deny Petitioner’s Medicare enrollment application, and to add his name to the Medicare preclusion list.

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Background

On December 26, 2019, the Oklahoma State Board of Medical Licensure and Supervision (Oklahoma Board) issued a verified complaint against Petitioner alleging unprofessional conduct.  CMS Exhibit (Ex.) 11.  The complaint was investigated and the Oklahoma Board accused Petitioner of seven violations of the state regulations.  Id. at 6.  On March 17, 2021, Petitioner voluntarily submitted to the Oklahoma Board’s jurisdiction and acknowledged that a hearing could result in sanctions.  CMS Ex. 9.  Petitioner was ultimately found guilty of two state regulations and was prohibited from engaging in venous stenting moving forward.  Id. at 3.

A second verified complaint was filed against Petitioner with the Oklahoma Board on October 26, 2021.  CMS Ex. 10.  Similar to the first complaint, the allegations of unprofessional conduct were related to stent procedures performed by Petitioner.  Id. at 1-2.  The Oklahoma Board found Petitioner guilty of ten violations of the state regulations.  Id. at 3.  The State of Oklahoma then requested that the Oklahoma Board conduct a hearing and impose disciplinary actions against Petitioner including the possibility of revoking his state medical license.  Id. at 4.

On July 8, 2022, Petitioner’s Oklahoma Medicaid contract was terminated for the unprofessional conduct outlined in the verified complaints.  CMS Ex. 4 at 20-22.  On July 11, 2022, Petitioner received a revised termination notice of his Oklahoma Medicaid contract.  CMS Ex. 4 at 23-25.

On July 13, 2023, the Oklahoma Board revoked Petitioner’s medical license without the right to reapply based on the findings of unprofessional conduct.  CMS Ex. 2.  In a letter dated July 12, 2023, the Oklahoma Attorney General’s Office reviewed the Oklahoma Board’s findings and agreed with the revocation of Petitioner’s medical license.  CMS Ex. 2 at 6.  As a result, the revocation was final.  CMS Ex. 2 at 4, 6.

On November 7, 2023, Petitioner applied to enroll in the Medicare program.  CMS Ex. 1.  By letter dated December 28, 2023, the Medicare contractor, Noridian Healthcare Solutions, advised Petitioner that his application to enroll was denied pursuant to 42 C.F.R. § 424.530(a)(14).  CMS Ex. 4 at 4.  As the notice letter explains, the contractor acted pursuant to 42 C.F.R. § 424.530(a)(14) because Petitioner’s participation in Oklahoma Medicaid had been terminated and his Oklahoma medical license had been revoked.  CMS Ex. 4 at 4.

The letter also advised Petitioner that the contractor was adding him to the CMS preclusion list, as authorized by 42 C.F.R. §§ 422.2, 422.222, 423.100, and 423.120(c)(6).  It explained that, if Petitioner requested reconsideration, this action would

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become effective on the date the reconsidered determination was issued.  CMS Ex. 4 at 4.

On June 24, 2024, Noridian issued a duplicate notification letter informing Petitioner that his enrollment application was denied pursuant to 42 C.F.R. § 424.530(a)(14).1  CMS Ex. 4 at 8.  The letter confirmed Petitioner’s placement on the preclusion list.  Id. 

On December 27, 2023, Novitas notified Petitioner that his Medicare enrollment in Oklahoma was revoked effective January 26, 2024, pursuant to 42 C.F.R. § 424.535(a)(12).  CMS Ex. 4 at 35-38.  The letter informed Petitioner that the basis for the revocation was his termination from the Oklahoma Medicaid program and that he was also being placed on the preclusion list.  Id. at 35.  A five-year reenrollment bar was also imposed.  Id.

On December 28, 2023, another Medicare contractor, Palmetto GBA Solutions, notified Petitioner that his Medicare enrollment in Georgia was revoked effective January 27, 2024, pursuant to 42 C.F.R. § 424.535(a)(12).  CMS Ex. 4 at 31-33.  The letter informed Petitioner that the basis for the revocation was his termination from the Oklahoma Medicaid program and that he was also being placed on the preclusion list.  Id. at 31.  A five-year reenrollment bar was also imposed.  Id.

On December 27, 2023, CGS notified Petitioner that his Medicare enrollment in Ohio was revoked effective January 26, 2024, pursuant to 42 C.F.R. § 424.535(a)(12).2  CMS Ex. 4 at 27-29.  The letter informed Petitioner that the basis for the revocation was his termination from the Oklahoma Medicaid program and that he was also being placed on the preclusion list.  Id. at 27.  A five-year reenrollment bar was also imposed.  Id.

Petitioner requested reconsideration of his revocations, enrollment denial and placement on the preclusion list.3  CMS Ex. 12.  In a reconsidered determination, dated December 10, 2024, a CMS hearing officer upheld the denial.  Id.  Petitioner timely appealed and that appeal is now before me.

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Summary judgment/decision based on the written record.  CMS filed a motion for summary judgment.  However, I also find that it may be decided based on the written record, without considering whether the standards for summary judgment have been met.

The February 12, 2025 Standing Order instructs the parties to list any proposed witnesses and to submit their written direct testimony.  Standing Order at 9 (February 12, 2025).  The order also directs the parties to indicate which, if any, of the opposing side’s witnesses the party wishes to cross-examine and explains that an in-person hearing is needed only if a party wishes to cross-examine the opposing side’s witnesses.  Id.  The parties list no witnesses.  Because there are no witnesses to be examined or cross-examined, an in-person hearing would serve no purpose, and I may decide this case based on the written record without considering whether the standards for summary judgment are met.4

Exhibits.  With its pre-hearing brief and motion for summary judgment (CMS Br.), CMS filed 12 exhibits (CMS Exs. 1-12).  With his pre-hearing brief (P. Br.), Petitioner submitted 2 exhibits (P. Exs. 1-2), both submitted as new evidence.

Petitioner has not objected to my admitting CMS’s exhibits.

New evidence.  Petitioner submits a March 21, 2025 letter to the Medical Board of California seeking the end of his clinical supervision requirement.  P. Ex. 1.  The letter was not submitted at the reconsideration level.  Petitioner also submits a March 25, 2025 letter from the Medical Board of California ending the clinical supervision requirement.  P. Ex. 2.  This letter was also not submitted at the reconsideration level.  CMS has not objected to my admitting the documents.  Nevertheless, unless I find that good cause exists for Petitioner’s submitting it, for the first time, at this level of review, I must exclude this evidence.  42 C.F.R. § 498.56(e).  Inasmuch as the documents are dated more than thirteen weeks after the CMS hearing officer issued the reconsidered determination, Petitioner obviously has established good cause for not submitting the letters at the reconsideration level.  They did not exist at that time.

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I admit into evidence CMS Exs. 1-12 and P. Exs. 1-2.

Discussion

The Medicare Program.  The Medicare program, Title XVIII of the Social Security Act (Act), is a federally-subsidized insurance program that provides health care benefits to the elderly, disabled, and those suffering from end stage renal disease.  Medicare is divided into four parts:

• Part A is the hospital insurance program.  It covers hospital services, post-hospital extended care, home health, and hospice care.  Act § 1811 (42 U.S.C. § 1395c);
• Part B, which is voluntary, is the supplementary medical insurance program, covering physician, home health, hospice, and other services.  Act § 1832 (42 U.S.C. § 1395k);
• Part C is the Medicare Advantage program, which allows its participants to enroll in “Medicare + Choice” plans, managed by organizations, such as health maintenance organizations, that receive a fixed payment for each enrollee.  Act § 1851 (42 U.S.C. § 1395w-21); and
• Part D is the voluntary prescription drug benefit program.  Act § 1860D-1 (42 U.S.C. § 1395w-101).

The Medicare program is administered by CMS, acting on behalf of the Secretary of Health and Human Services.  CMS regulates the Medicare enrollment of providers and suppliers.  Act § 1866(j)(1)(A).  Physicians or other practitioners, such as Petitioner, may participate in the program as “suppliers” of services; however, they must enroll in the program in order to receive Medicare payments.  Act § 1861(d) (42 U.S.C. § 1395x(d)); 42 C.F.R. § 400.202.

CMS contracts with Medicare administrative contractors, who process and pay reimbursement claims and perform other duties necessary to carry out program purposes.  Act § 1842 (42 U.S.C. § 1395u).  Contractors pay claims to “providers” (Part A) and “suppliers” (Part B). 

1. CMS may deny Petitioner’s enrollment in the Medicare program because the Oklahoma Medicaid agency suspended his participation in the program.5

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Enrollment denial.  CMS may deny a supplier’s enrollment in the Medicare program if the supplier “is currently terminated or suspended (or otherwise barred) from participation” in a state Medicaid program or any other federal health care program, or if the supplier’s license “is currently revoked or suspended” in a state other than that in which the supplier is enrolling.  In determining whether to deny enrollment, CMS considers:  A) the reason(s) for the termination, suspension, or revocation; B) whether the supplier is currently terminated or suspended from more than one program, has been subject to any other sanctions or had any other final adverse actions imposed against it; and C) any other information CMS deems relevant.  42 C.F.R. § 424.530(a)(14).

So long as the regulatory elements for denial of enrollment under section 424.530(a) are present, I must affirm.  John A. Hartman, D.O., DAB No. 2911 at 17 (2018); Douglas Bradley, M.D., DAB No. 2663 at 6-7, 13-14 (2015) (citing Letantia Bussell, M.D., DAB No. 2196 at 10 (2008)).

Petitioner’s misconduct and the loss of his license.  In 2019 and 2021, the Oklahoma Board issued verified complaints against Petitioner alleging unprofessional conduct related to his placement of stents.  CMS Exs. 10, 11.  The complaints alleged that Petitioner’s conduct caused actual harm to his patients.  Id.  The Oklahoma Board found Petitioner guilty of 17 total violations.  CMS Ex. 10 at 3; CMS Ex. 11 at 6.

On July 13, 2023, the Oklahoma Board revoked Petitioner’s medical license without the right to reapply based on the findings of unprofessional conduct.  CMS Ex. 2.  The Oklahoma Attorney General agreed with the Board’s finding and the revocation was made final.  Id. at 6.

In a letter dated July 8, 2022 and revised on July 11, 2022, the Oklahoma Medicaid agency advised Petitioner that he was indefinitely suspended from the state’s Medicaid program because of unprofessional conduct related to the poor placement of stents.  CMS Ex. 4 at 20, 23.  The letter further explained that an expert reviewed eight of Petitioner’s patient records and found that stents were placed unnecessarily in one or more cases and that incorrectly sized stents were also used.  Id.  The expert also found that other cases reviewed showed a pattern of unnecessary medical procedures.  Id. at 21, 24.  The agency stated that it was extremely concerned for the health and safety of its members and that Petitioner’s behaviors created an imminent risk of harm to Oklahoma Medicaid patients.  Id. at 22, 25.

Thus, at the time Petitioner applied to enroll in the Medicare program (November 7, 2023) through the time the reconsidered determination was issued (December 10, 2024), Petitioner was “currently” suspended from participating in the Oklahoma Medicaid

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program.  The reason for the suspension related to his performance as a provider of services.  CMS was therefore authorized to deny his Medicare enrollment application under 42 C.F.R. § 424.530(a)(14).  So long as CMS is legally authorized to deny an enrollment application, I must sustain its decision to do so.  Edward J.S. Picardi, M.D., DAB No. 3045 at 11 (2021); City of Sugar Land, DAB No. 2719 at 8 (2016).

Although Petitioner concedes that his Oklahoma license was revoked and his Oklahoma Medicaid participation was suspended, he points out that he has been admitted to practice in California and his prior clinical practice supervision requirements have been lifted.  P. Br. at 4.

At the time the Medicare contractor denied his Medicare enrollment, Petitioner’s Oklahoma license had been revoked without the ability to reapply, which means that his state license was “currently” suspended, and the contractor was authorized to deny enrollment.  Because Petitioner’s medical license was revoked at the time that the Medicare contractor denied his enrollment, CMS was authorized to cite his Oklahoma license revocation as a basis for the denial.

Further, as outlined in the reconsidered determination, in denying enrollment, CMS has carefully considered the relevant regulatory factors:

• It considered the underlying reasons for the revocation of his license and suspension from Oklahoma Medicaid and noted that the Oklahoma Board had found him guilty of violations that included dishonorable or immoral conduct which was likely to cause harm to the public.  CMS Ex. 12 at 6; see 42 C.F.R. § 424.530(a)(14)(i)(A).
• CMS acknowledged that it was not aware of any other license or Medicaid suspensions or terminations outside of Oklahoma, but it considered the conduct underlying the revocation of his Oklahoma license, as well as his termination from the Oklahoma Medicaid program to be very serious and to implicate very serious patient safety concerns, which weigh in favor of the denial.  CMS Ex. 12 at 6; see 42 C.F.R. § 424.530(a)(14)(i)(B).
• With respect to “any other information CMS deems relevant,” CMS considered that it appears that Petitioner engaged in venous stenting after agreeing with the Oklahoma Board that he would not and that this behavior raises concerns of repeated violations.  CMS Ex. 12 at 6; see 42 C.F.R. § 424.530(a)(14)(i)(C).

CMS thus reasonably exercised its discretion to deny Petitioner’s Medicare enrollment.  Because the regulatory elements for denial of enrollment under section 424.530(a)(14) are present, I cannot disturb its determination.

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Petitioner argues instead that he did not receive notice of his suspension from Oklahoma Medicaid and, therefore, missed the ability to appeal.  P. Br. at 2.  Petitioner also argues that he believed that when he voluntarily surrendered his medical license in Oklahoma, it would resolve any issues regarding his practice in the state.  Id. at 3.  Petitioner states that because he believed the matter was resolved, neither he nor his counsel appeared for any additional proceedings in Oklahoma.  Id.  Although this all may be true, it does not change the fact that Petitioner’s Oklahoma medical license was revoked and he was suspended from the Oklahoma Medicaid program.  As a result, I cannot disturb CMS’s determination to deny his enrollment.

2. CMS had a legitimate basis to revoke Petitioner’s Medicare enrollment and billing privileges under 42 C.F.R § 424.535(a)(12) because Petitioner was terminated from participating in Oklahoma’s Medicaid program and Petitioner has no appeal of that termination pending.

Revocation.  CMS may revoke a supplier’s Medicare enrollment when the following circumstances are met:

(i) The provider or supplier is terminated, revoked or otherwise barred from participation in a State Medicaid program. . . . 

(ii) Medicare may not revoke unless and until a provider or supplier has exhausted all applicable appeal rights or the timeframe for filing an appeal has expired without the provider or supplier filing an appeal.

42 C.F.R. § 424.535(a)(12)(i)-(ii).

Petitioner neither disputes that the Oklahoma Board revoked his license and suspended Petitioner from participating in the Oklahoma Medicaid program nor that Petitioner has no appeal of that revocation/suspension pending or an expired right to file an appeal.  Therefore, CMS legitimately revoked Petitioner’s Medicare enrollment under 42 C.F.R. § 424.535(a)(12).

Petitioner does again argue that he did not receive notice of his suspension from Oklahoma Medicaid and, therefore, missed the ability to appeal.  P. Br. at 2.  Petitioner also argues that he believed that when he voluntarily surrendered his medical license in Oklahoma, it would resolve any issues regarding his practice in the state.  Id. at 3.  Again, although this may be the case, it does not change the fact that Petitioner’s Oklahoma medical license was revoked and he was suspended from the Oklahoma Medicaid program and no appeals on either the license revocation or Medicaid suspension are pending.

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3. CMS acted within its authority when it added Petitioner to its preclusion list because he engaged in behavior for which CMS could have revoked his Medicare enrollment, had he been enrolled, and because CMS reasonably determined that the conduct that would have led to his revocation is detrimental to the best interests of the Medicare program.  Further, CMS acted within its authority when it added Petitioner to its preclusion list because he was revoked from Medicare in Oklahoma, Georgia, and Ohio pursuant to 42 C.F.R. § 424.535(a)(12); because he was currently under a reenrollment bar; and because CMS reasonably determined that the conduct that led to the revocation is detrimental to the best interests of the Medicare program.

The preclusion list.  Effective January 1, 2019, CMS implemented a “preclusion list” as part of its effort to “prevent fraud, waste, and abuse, and to protect Medicare enrollees,” particularly with respect to prescription drug abuse.6  Pursuant to 42 C.F.R. § 422.2 (Part C) and 42 C.F.R. § 423.100 (Part D), CMS’s “preclusion list” includes individuals who have engaged in behavior, other than that stated in section 424.535(a)(3),7 for which CMS could have revoked their Medicare enrollment had they been enrolled, and whose conduct, in CMS’s view, is detrimental to the best interests of the Medicare program.  In determining whether conduct is detrimental, CMS considers:  1) the seriousness of the conduct underlying the revocation; 2) the degree to which that conduct could affect the integrity of the Medicare program; and 3) any other evidence that it deems relevant.

Petitioner’s Medicare enrollment could have been revoked solely pursuant to 42 C.F.R. § 424.535(a)(12), which authorizes CMS to revoke the Medicare enrollment of a supplier who has been terminated, revoked, or otherwise barred from participating in a state Medicaid program.

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As discussed above, CMS also reasonably determined that Petitioner’s conduct is detrimental to the Medicare program.  It found his underlying conduct problematic, indicating that Petitioner does not adhere to rules and regulations and demonstrating an unwillingness to accept authority.  Such behavior could be replicated in the Medicare program.  CMS also found that Petitioner’s very serious misconduct, as well as his termination from the Oklahoma Medicaid program, implicated patient safety concerns.  CMS Ex. 12 at 6-7, 8-9.

CMS has thus established a basis for placing Petitioner on the preclusion list, and I must therefore uphold its determination to do so.  See Wendell Foo, M.D., DAB No. 2904 at 3 (2018); Wassim Younes, M.D. and Wassim Younes, M.D., P.L.C., DAB No. 2861 at 8 (2018) (citing Patrick Brueggeman, D.P.M., DAB No. 2725 at 15 (2016)).

4. I do not have the authority to review the length of the re-enrollment bar.

Whenever CMS has properly imposed a revocation on a supplier, CMS must also determine how long the supplier will be barred from seeking reenrollment as a supplier.  The regulations at 42 C.F.R. § 424.535(c)(1) provide that the re-enrollment bar “[b]egins 30 days after CMS or its contractor mails notice of the revocation and lasts a minimum of 1 year, but not greater than 10 years . . . depending on the severity of the basis for revocation.”  However, the length of the re-enrollment bar is not subject to ALJ review.  Vijendra Dave, M.D., DAB No. 2672 at 9 (2016).  Therefore, I cannot review whether a five-year reenrollment bar is appropriate in this case.  

5. Petitioner’s other arguments are not a basis to overturn the revocation of Petitioner’s Medicare enrollment and billing privileges

Petitioner goes on to argue that CMS’s revocation decision was arbitrary and capricious and an “abuse of discretion,” and should be set aside, because CMS failed to adequately consider all of the relevant evidence of consequence when arriving at its decision.  P. Br. at 1-2, 6.  In Petitioner’s view, the actions taken in Oklahoma should not be able to negatively affect his ability to treat patients in California.  Petitioner’s contention that I may overturn CMS’s revocation and denial of his Medicare enrollment and billing privileges as “arbitrary and capricious” misunderstands my role as an administrative law judge in the administrative appeal process.  The arbitrary and capricious standard, codified in section 706 the Administrative Procedure Act (APA), is a standard for court review of final agency actions.  5 U.S.C. § 706.  My role differs from that of a federal court reviewing final agency actions.  In administrative proceedings governed by 42 C.F.R. Part 498, neither CMS’s revocation determination nor my decision reviewing that determination is a final agency action.  Arriva Med., LLC, DAB No. 2934 at 15 (2019); see also 42 C.F.R. § 498.90 (providing that the appellate decision of the Departmental Appeals Board (DAB) is the final agency action that may be appealed to federal court).  As an appellate panel of the DAB held in Hanover Hill Health Care Ctr.,

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“[n]othing in the APA . . . applies the ‘arbitrary and capricious standard’ to Board review of an [administrative law judge] decision on behalf of the Secretary . . . .”  DAB No. 2507 at 7 (2013); see also Cal Turner Extended Care Pavilion, DAB No. 2030 at 7 (2006) (discussing “the distinction between the oversight role of a federal court reviewing agency decisions to determine if an adequate basis is articulated and the internal agency appeals process for formulating final agency action”).

Moreover, appellate panels of the DAB have repeatedly rejected this line of argument.  See, e.g., Arriva, DAB No. 2934 at 15-16 (and cases cited therein).  My review of CMS’s discretionary decision to revoke Petitioner’s Medicare enrollment and billing privileges “is ‘limited to deciding whether CMS had a valid legal basis for that action.’”  Id. at 15 (quoting Care Pro Home Health, Inc., DAB No. 2723 at 5 (2016)).  I am not authorized to substitute my discretion for CMS’s discretion.  Id. at 15-16 (citing Abdul Razzaque Ahmed, M.D., DAB No. 2261 at 17, 19 (2009)).  Furthermore, to the extent Petitioner is seeking equitable relief from her revocation, I cannot grant such relief.  Id. at 16 (citing Central Kan. Cancer Inst., DAB No. 2749 at 10 (2016)).

Petitioner argues that he provides exceptional care to his patients in California and that it would be a disservice to these patients if Petitioner is unable to provide services.  See P. Br. at 7-8.  Petitioner also states that he has regained the ability to practice in California without supervision.  P. Ex. 2.  I construe these arguments as an appeal to equity.  In other words, Petitioner is arguing that revocation of his Medicare enrollment is unfair under the circumstances.  However, an administrative law judge is not authorized to provide equitable relief by reimbursing or enrolling a supplier that does not meet statutory or regulatory requirements.  US Ultrasound, DAB No. 2302 at 8 (2010) (citing Regency on the Lake, DAB No. 2205 (2008)).  I therefore find no basis to overturn CMS’s reconsidered determination.

Lastly, Petitioner asserts that CMS should take action similar to HHS Office of the Inspector General when deciding that individuals who have lost a license in one state may pursue a license in another state without being subject to continued exclusion.  P. Br. at 7.  As I previously explained, the nature of my review is whether CMS was authorized to revoke Petitioner’s enrollment pursuant to 42 C.F.R. § 424.535(a)(12) and deny Petitioner’s enrollment pursuant to 42 C.F.R. § 424.530(a)(14); see Dr. Robert Kanowitz, DAB No. 2942 at 4 (2019).  Though I have no reason to question the veracity of the aforementioned interpretation of the HHS OIG’s decision-making by Petitioner, the sole matter before me is whether CMS was authorized to revoke and deny Petitioner’s Medicare enrollment, and not whether I or the HHS OIG would have taken the same action.  As discussed in detail above, CMS had a legitimate basis to revoke and deny Petitioner’s enrollment.

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Conclusion

CMS may deny Petitioner Medicare enrollment pursuant to 42 C.F.R. § 424.530(a)(14) because the Oklahoma Medicaid agency suspended his Medicaid participation.  Pursuant to 42 C.F.R. § 424.535(a)(12), CMS may revoke Petitioner’s Medicare enrollment and billing privileges in Oklahoma, Georgia, and Ohio, because Petitioner was terminated from participating in Oklahoma’s Medicaid program and Petitioner did not appeal that termination.  CMS may add him to the preclusion list because he engaged in behavior for which CMS could have revoked his Medicare enrollment, had he been enrolled, and because CMS reasonably determined that the conduct that would have led to his revocation is detrimental to the best interests of the Medicare program.  CMS may also add him to the preclusion list because his Medicare enrollment was revoked, he was under a current reenrollment bar, and because CMS reasonably determined that the conduct that led to his revocation was detrimental to the best interests of the Medicare program.

I therefore affirm CMS’s determinations.