as the supreme court in this part about the sat is this serves important purposes for example allows the department of health and human services to apply its expertise to potentially complex and potentially individual issues of medical needs it allows the agency to create an agency decision and compile an administrative record suitable for judicial review and it also just helps to ensure the efficient and equitable management of this is vast government benefits none the less in this case plaintiffs stick prespective relief governing the future processing of their claims for medicare reimbursement and the district court issued a preliminary injunction that precludes medicare contractors from applying  particular local coverage determination that is a particular substantive standard for evaluating medical necessity to dr robert odell's claims absent individual lives medical records review the district court eroded numerous review of decisions of the agency it instructs courts to conduct a review on the administrative record to defer to the secretary's factual findings as long as there's a party by substantial evidence but here where it's like you just do not  claims are wholly collateral to their entitlement to benefits which is the standard the final i didn't ring or to the contrary if the court looks at the amended complaint it's very clear that the whole purpose of this suit is to obtain reimbursement plaintiffs complain that they are denied reimbursement because the contractor applies the wrong l c t to their claims and they seek perspective relief from have locution of the l c d because they want to be reimbursed in the future without having to go how would it work if you have no imagine a hypothetical where the the contractor has some sort of anonymous against a particular provider and so they just deny now all of the claims from the provider so the provider goes through the administrative appeal process situation i think the st remedy in that situation is of course the claims appeals as a beneficiary would be able to seek something like a national coverage determination or a change to a local coverage determination which could apply prospectively of course congress did not make that mechanism available to providers but that's perhaps not surprising because it's beneficiaries who the system is supposed to serve and i think that as a as a at on a more practical level there are various things about how the system works that would serve as a sort of a backstop against this for example just to provide evidence and monitors its contractors and if if a contractor was routinely denying claims from a particular provider for some worth noting that the local coverage determination process involves extensive public participation before local coverage determination can even be issued so it's difficult to imagine an l c d getting through a process that really you know singled out one provider my provider in the claim processing claims processing process could say this contractor is always denying the claims and that's wrong and in reviewing denials of claims the agency could could evaluate that and then i think if for example of the provider got up to the appeals council and the appeals council said well the contractor is doing is really wrong the provider of course could say that appeals co decision in trying to get future claims reimbursed by congress did not provide you know a special route to procedural review like it did for a beneficiary is but the supreme court emphasised in rigor that that is a feature not struggling with that little bit of like if we say that dr adele needs to do more to put his complaint in front of the agency what more are we going to get from the agency than what we've already have passed a decision the court could get much more so for example i've seen from a contractor that dr goodall i believe has claims pending before the appeals council the highest level of administrative review right now and if the appeals council were to administrative record that would allow the court to rule on the issues presented in a concrete way instead of here where dr odell sites kind of a laundry list of administrative decisions at lower levels that he thinks went his way without much baker from pursuing the special procedural route that congress created for beneficiaries the fact that congress did not create a special procedural route for providers a purpose does not mean that congress intended for providers to be able you say are being wrongly denied at the initial level and you have to administrative leave appeal every single one congress did not intend for a decision on one claim to sort of allow for the decision of all future claims t to challenge that claim by claim that is our position i certainly put the preliminary injunction both precludes the contractor going forward from applying the local coverage determination to claims you know that have not been presented yet but i understand what your honor is saying that there are also claims that are already in the pipeline for claims that are already in the pipeline and the same claim by claim process that congress established applies and i don't i think even if there could be questions on the margin about reimbursed without having to go through administrative appeals he also has not shown the irreparable injury other than the delay related hardship that congress recognized many participants in the medicare system might experience and that d ministr exhaustion also would not be futile both in the sense that he can get relief through the administrative process and in the broader sense that's part of that which is that exhaustion here would certainly promote congress purposes i giving the agency an opportunity to apply its expertise to the potentially very individualized issues that claims present you know each patient is different each patient may have different needs different symptoms so it's not at all clear that it's even appropriate to be thinking about that we don't think the treatment was needed or we think that treatment was applied and appropriately it seems to be that they're just looking at this and saying you know we think rule one applies to doctors they want to apply and nobody is really doing much of  i think that number one it's not clear especially given the strange way in which plaintiffs have brought this suit it's not actually clear what is going on but and certainly the question of which l c d applies to a given claim could be very individualized pending on the patient but in any of that this is just like the policy the policy that was it at issue in ringer where the plaintiffs claimed that unlawful a j just action was causing their claims to be denied at the st level of administrative review and that they were being sort of improperly forced to appeal james rhythm granting their claims and the supreme court said that that was not a basis to excuse for a five k there or there was also kind of an across the board policy so even if you think there is one  many years to the administrative process and it is safe to say and has pled below the treatment that he was rendering is nearly identical the process he was rendering is nearly identical and in this case the just as a general matter could congress create a scheme where every claim has to be presented individually and you know you're not making a constitutional challenge here to the authority of congress to create such a s know we've not made a constitutional claim or argument against the process itself that's correct we understand and we participated in the process what is being really approached  over and over again that becomes really the issue below n iron rule when it is the best is the best way that we can describe what was taking place at the contractor level why is this completely irrelevant local coverage determination taken off the shelf five to  presenting and we're currently continuing to present we have many claim spending throughout the system but more importantly i think the original claims that made it all way to the medicare appeals council level was directly on point in this issue we just don't have a contractor who will all have that determination so if your point is that medicare contractor can do whatever they want to do or irrationally on basis we don't believe that's the case know we're arguing a waiver for any further presentment we believe we presented all we have to the highest level of the medicare deals process the unfortunate aspect is that you can appeal a win if we if we win continuously up through we can get to the district who are in the traditional fashion in which you do that and i believe that was you know i don't i can't speak for the miners that were working at the time when the materials council took this on the consideration  of process but we could never get the contractor to appreciate where and when we took the jurisdictional discovery that was permitted by the district or below they were very blatant in saying we don't care how many wins  case although yes it it was a case in which the reasonable this in the sense of the medical treatment might have been decided but the underlying threshold issue of whether or not that l c d had anything to do with treatment was way interferes with the decision making of the agency on a prospective basis was suggested by counsel of the secretary it merely says you may not engage in the mechanical application of this particular l will these also keep in mind what was said before the prospective versus retroactive process and these findings or process of more talk about all other what we're talking about the relevant application of simply analyse we're not that we go into medical necessity are reasonable those d issues were not cost whatsoever we simply didn't want the mechanical application of mousy do that had absolutely no relevance to the process so we believe just well where some limited subject matter discovery on that and spoke to the medical director for a ready and he was simply very flippant he really didn't care that this was being picked up it was going to continue to be applied whatever the we have no problem with that i'll see barry once again we just were asking that it not be mechanically applied to all claims processed and the longer it was just to the point where we thought we'd have these answers questions answered and their contractors are i mean there but the fundamental problem i've still struggling with is when you can say oh we're just objecting to the application of the l c d i mean you are making a procedural challenge to how the agency processes your claims and what i  have trouble seeing is what the jurisdictional authority is for considering such a challenge outside of the context of an individual d claim that has been presented to the agency and appeal under four or five  we've already presented these plans and live by the rules and taken up to the highest level in medicare appeals council traditionally it's only if they disagree with us that we would then have the ability to take this further into district court but what happens when you're complaining about an unwritten rule governing the processing of their medicare reimbursement things but what they're really complaining about is just the way that there are flames are are considered for reimbursement at this point setting kildare that a plaintiff can't just you know stick the same policy on a reimbursement dispute and thereby circumvent six section four or five and indeed i suspect that there are probably a lot of medicare providers and patients out there who may prefer to have you know more certainty about in advance about the reimbursed ability of their their or their services and you know would like an advance some kind of advance ruling from a court about that but of course the reverse that that is not allowed and plaintiffs here should not be allowed to get around ecause why isn't that enough to say that the agencies have a chance to address this sure a couple of responses to that st of course plaintiffs are not seeking review of that decision which is what section four of five to require is he also plaintiffs rely those to the medicare appeals council but they did not do so at the a l j didn't have authority to declare d more broadly in this claims process in context which l c d implies and again his decision is