Cosmetic Surgery Associates of New York, DAB CR6923 (2026)

DECISION

I affirm the determination of the Centers for Medicare & Medicaid Services (CMS) that the effective date for the reactivation of Petitioner’s Medicare billing privileges is September 29, 2025.

I.  Procedural History

On March 9, 2026, Petitioner requested a hearing to dispute the effective date for the reactivation of its Medicare billing privileges.  On March 11, 2026, the Civil Remedies Division acknowledged the hearing request, provided a prehearing submission schedule to the parties, and issued Administrative Law Judge Benjamin Zeitlin’s Standing Order.1  On April 7, 2026, CMS filed a prehearing exchange, which included 10 proposed exhibits.  Petitioner filed its exchange on June 3, 2026 with one exhibit.  CMS filed a reply on June 15, 2026.

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II.  Admission of Evidence

Absent objection, I admit all of the proposed exhibits into the record.  See Standing Order ¶ 10; Civil Remedies Division Procedures (CRDP) § 14(e).

III.  Decision on the Written Record

The parties were directed  to submit written direct testimony for any witnesses they wanted to offer.  Standing Order ¶ 11.  They were also informed as follows: 

If the parties either do not file any written direct testimony or the parties do not request to cross-examine any of the witnesses from whom written direct testimony has been submitted, I will consider such actions by the parties to serve as a constructive request for a decision on the written record because there will be no reason to hold an in-person hearing.

Standing Order ¶ 7(g)(iii); see also CRDP §§ 16(b), 19(b), (d).  The Standing Order further advised:  “Unless a hearing is required for cross-examination of a witness or witnesses, the record will be closed and the case will be ready for a decision after all the submission deadlines have passed.”  Standing Order ¶ 14.

CMS did not submit any written direct testimony.  Petitioner submitted the written direct testimony of Lauren Blauer.  However, CMS did not request to cross-examine Ms. Blauer.  Therefore, I decide this case on the written record.  Anil Hanuman, D.O., DAB No. 3080 at 11-12 (2022).

IV.  Issue

Whether September 29, 2025, is the correct effective date for the reactivation of Petitioner’s Medicare billing privileges.

V.  Jurisdiction

I have jurisdiction to decide the issue in this case.  42 C.F.R. § 498.3(b)(15).

VI.  Findings of Fact

1. Petitioner is a medical practice who was enrolled in the Medicare program.  See CMS Ex. 1.
2. In a March 31, 2025 notice, a CMS contractor requested Petitioner revalidate its enrollment by June 30, 2025.  CMS Ex. 2.  The notice was mailed to Petitioner’s

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address in Harrison, New York.  Id.

3. On July 7, 2025, the CMS contractor issued a notice letter placing a stay of enrollment because Petitioner failed to respond to the revalidation request.  CMS Ex. 4.  The CMS contractor sent a letter deactivating Petitioner on August 15, 2025 for failing to respond to the March 31, 2025 revalidation request.  CMS Ex. 5.
4. On September 29, 2025, the CMS contractor received a CMS 855-B reactivation application from Petitioner.  CMS Exs. 3, 6.
5. In a November 10, 2025 notice, the CMS contractor approved Petitioner’s application for the reactivation of Medicare billing privileges, effective September 29, 2025.  CMS Ex. 7.  This resulted in Petitioner having a billing gap from July 1, 2025 through September 28, 2025.  Id.
6. On November 21, 2025, Petitioner requested reconsideration of the effective date for reactivation.  CMS Ex. 8.
7. In a February 6, 2026 reconsidered determination, the CMS contractor upheld the September 29, 2025 effective date of reactivation.  CMS Ex. 10.

VII.  Conclusions of Law and Analysis

1. The effective date of reactivation for Petitioner’s Medicare billing privileges is September 29, 2025, because CMS received Petitioner’s reactivation enrollment application on September 29, 2025, and a CMS contractor was able to process that application to approval.

The Social Security Act (Act) authorizes the Secretary of Health and Human Services (Secretary) to promulgate regulations governing the enrollment process for providers and suppliers.  42 U.S.C. §§ 1302, 1395cc(j).  A “Supplier” for Medicare program purposes  includes “Physical therapists in private practice.”  42 C.F.R. § 424.502; see also 42 U.S.C. § 1395x(d), (p); 42 C.F.R. § 410.60(a)(3)(ii), (c).  A supplier must enroll in the Medicare program to receive payment for covered items or services.  42 U.S.C. §§ 1395n(a), 1395u(h)(1); 42 C.F.R. § 424.505.  To enroll, the supplier must submit an enrollment application and provide all required information.  42 C.F.R. § 424.510(a).  To maintain enrollment, a supplier must recertify the accuracy of its enrollment information every five years.  42 C.F.R. § 424.515.  To do this, a supplier “must submit to CMS the applicable enrollment application with complete and accurate information and applicable supporting documentation within 60 calendar days of [CMS’s] notification to resubmit and certify to the accuracy of its enrollment information.”  42 C.F.R. § 424.515(a)(2).

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To reactivate billing privileges, the supplier must recertify that its reenrollment information currently on file with CMS is correct and furnish any missing information.  42 C.F.R. § 424.540(b)(1).  Further, CMS may, for any reason, require a deactivated supplier file a CMS-855 enrollment application to reactive billing privileges.  42 C.F.R. § 424.540(b)(2).  When a supplier seeks reactivation, “[t]he effective date of a reactivation of billing privileges under this section is the date on which the Medicare contractor received the . . . supplier’s reactivation submission that was processed to approval by the Medicare contractor.”  42 C.F.R. § 424.540(d)(2).  CMS may not pay a supplier for any health care items or services provided during the period of deactivation.  42 C.F.R. §§ 424.540(e), 424.555(b); 86 Fed. Reg. 62,240, 62,359-60 (Nov. 9, 2021); see also Goffney v. Becerra, 995 F.3d 737, 743 (9th Cir. 2021).

Petitioner requests that the gap in billing privileges be removed because it continued to treat patients during that time period and because it never received the initial letter from the contractor requesting revalidation.  Specifically, Petitioner asserts that although the letter was mailed to Petitioner’s practice address, it never received the letter.  Petitioner argues that had it received the letter it would have been able to take appropriate action and avoid the billing privileges gap.  To support its argument, Petitioner submits the testimony of office manager, Ms. Lauren Blauer.  P. Ex. 1.  Ms. Blauer explained that she oversees the day-to-day office operations and that she promptly addresses any CMS related correspondence.  Id.  She also explains that when Petitioner became aware of the problem with its billing in July, Petitioner immediately attempted to access PECOS and experienced numerous issues.  Id.  Ms. Blauer explains that eventually a consultant was hired and an enrollment application was finally able to be submitted on September 29, 2025.  Id.

However, I am unable to modify the effective date for reactivation.  As stated above, the standard for setting the effective date for reactivation is the date that CMS receives the reactivation application when that application is processed to approval.  42 C.F.R. § 424.540(d)(2).  In this case, the effective date of reactivation is September 29, 2025, because that is the date that the reactivation application was received, and that application was processed to approval.

I understand Petitioner’s argument that it did not receive the original March 2025 notice letter requesting that it revalidate its enrollment.  But Petitioner confirmed that the mailing address the CMS contractor used was correct.  In any event, my jurisdiction is limited to determining whether CMS assigned Petitioner the correct date of reactivation.  See 42 C.F.R. § 498.3(b)(15) (effective date for supplier approval is an appealable initial determination).  I do not have jurisdiction to review CMS’s decision to deactivate Petitioner’s Medicare billing privileges.  See 42 C.F.R. §§ 424.545(b), 424.546(f) (CMS has the sole authority to consider any rebuttal to the deactivation filed by a supplier); Michael B. Zafrani, M.D., DAB No. 3075 at 3, 8 (2022).

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Ultimately, I am sympathetic to Petitioner’s situation and the frustrations it must have encountered with its experience accessing PECOS.  However, I cannot ignore regulations that the Secretary has promulgated.  The regulations require a reactivation effective date of September 29, 2025.  42 C.F.R. § 424.540(d)(2).  Further, I cannot direct CMS to pay Petitioner for health care items or services provided to Medicare beneficiaries during the period of deactivation because the regulations expressly prohibit CMS from doing so.  42 C.F.R. §§ 424.540(e), 424.555(b); 86 Fed. Reg. 62,240, 62,359-60 (Nov. 9, 2021); see also Goffney v. Becerra, 995 F.3d 737, 743 (9th Cir. 2021).  I only have authority to determine if CMS properly set the date of reactivation.  See 42 C.F.R. § 498.3(b)(15).  In this case, CMS did so.  

VIII.  Conclusion

The effective date for the reactivation of Petitioner’s Medicare billing privileges and the reassignment of Medicare benefits is September 29, 2025.