United States Court of Appeals

FOR THE DISTRICT OF COLUMBIA CIRCUIT

Argued May 16, 2005 Decided July 13, 2005

No. 04-5366

HEARTLAND REGIONAL MEDICAL CENTER, F/K/A HEARTLAND

HOSPITAL,

APPELLANT

v.

MICHAEL O. LEAVITT, IN HIS OFFICIAL CAPACITY AS

SECRETARY OF HEALTH AND HUMAN SERVICES,

APPELLEE

Appeal from the United States District Court

for the District of Columbia

(No. 95cv00951)

Donald B. Verrilli, Jr. argued the cause for appellant. With

him on the briefs were Michael B. DeSanctis, Elizabeth G.

Porter, Christopher L. Crosswhite, and David H. Robbins.

Michael F. Ruggio entered an appearance.

Christine N. Kohl, Attorney, U.S. Department of Justice,

argued the cause for appellee. With her on the brief were Peter

D. Keisler, Assistant Attorney General, Kenneth L. Wainstein,

U.S. Attorney, and Barbara C. Biddle, Assistant Director.
2

Before: SENTELLE, RANDOLPH, and GARLAND, Circuit

Judges.

Opinion for the Court filed by Circuit Judge GARLAND.

GARLAND, Circuit Judge: Heartland Hospital appeals from

the district court’s denial of its motion to enforce a judgment

that it obtained in 1998. The district court rested its decision on

the ground that the judgment did not require the remedy

Heartland seeks -- a direction that it is entitled to “sole

community hospital” status under the Medicare statute and to

reimbursement in accordance with such status. We agree with

the district court and affirm the denial of the hospital’s motion.

I

The federal Medicare program reimburses hospitals for the

cost of medical care for older persons and other eligible

individuals. Medicare operates according to a prospective

payment system (PPS), under which hospitals are paid a fixed

rate based on a patient’s diagnosis. 42 U.S.C. § 1395ww(d). A

hospital is exempt from PPS -- and therefore eligible for higher

payments based on its historic costs -- if it qualifies as a “sole

community hospital” (SCH). Id. § 1395ww(d)(5)(D)(i). At the

relevant time, the Medicare statute defined an SCH as any

hospital:

(I) that [the Department of Health and Human

Services (HHS)] determines is located more than 35

road miles from another hospital, [or]
3

1A hospital also qualified as an SCH if it was “designated by

[HHS] as an essential access community hospital.” 42 U.S.C. §

1395ww(d)(5)(D)(iii)(III) (1992). That provision is not at issue in this

case.

2

In 1999, Congress amended the Medicare statute to provide that

an urban hospital that “would [otherwise] qualify . . . as a sole

community hospital” shall be treated as “being located in [a] rural

area” for purposes of determining SCH status. 42 U.S.C. §

1395ww(d)(8)(E). Based on the new provision, Heartland received

SCH status as of January 1, 2000. This appeal therefore concerns

Heartland’s status only from 1992 through 1999.

(II) that, by reason of factors such as the time

required for an individual to travel to the nearest

alternative source of appropriate inpatient care . . . ,

location, weather conditions, travel conditions, or

absence of other like hospitals . . . , is the sole source

of inpatient hospital services reasonably available to

individuals in a geographic area. 

42 U.S.C. § 1395ww(d)(5)(D)(iii) (1992).1

The Medicare statute directed HHS to “promulgate a

standard for determining whether a hospital meets the criteria

for classification as a sole community hospital under” clause (II)

of the above definition. Id. § 1395ww(d)(5)(D)(iv). Under the

regulations promulgated pursuant to that direction, and in effect

during the relevant period, a hospital qualified as an SCH under

clause (II) only if it was “located in a rural area” and met other

listed criteria. 42 C.F.R. § 412.92(a) (1992). Thus, under the

regulations, a hospital located fewer than 35 miles from another

hospital -- and thus ineligible under clause (I) -- could not obtain

SCH status unless it was located in a rural area. Id.2 HHS
4

3At the time, an MSA was defined as “either a city with a

population of at least 50,000, or a Bureau of the Census urbanized area

of at least 50,000 and a total metropolitan statistical area population

of at least 100,000.” Notice of Final Standards for Establishing

Metropolitan Statistical Areas Following the 1980 Census, 45 Fed.

Reg. 956, 956 (Dep’t of Commerce Jan. 3, 1980).

4To obtain SCH status, a hospital must first apply to its Medicare

fiscal intermediary. 42 C.F.R. § 412.92(b)(1)(i). The intermediary

then forwards the application and its recommendation to the

appropriate regional office of the Health Care Financing

Administration (HCFA), see infra note 5, which decides whether to

grant the application. Id. § 412.92(b)(1)(iv), (v). The hospital may

appeal HCFA’s decision to the Provider Reimbursement Review

Board, 42 U.S.C. § 1395oo(a), and ultimately to a federal district

court, id. § 1395oo(f).

justified this “rural location requirement” on the ground that

“urban areas generally have better roads, faster snow-clearing,

and the choice of more available hospitals.” Medicare

Geographic Classification Review Board, Procedures and

Criteria, Final Rule, 56 Fed. Reg. 25,458, 25,483 (June 4, 1991).

For purposes of SCH eligibility, a “rural area” was defined as

“any area outside an urban area,” and an “urban area” was

defined as a “Metropolitan Statistical Area (MSA) . . . as defined

by the Executive Office of Management and Budget.” 42 C.F.R.

§ 412.62(f)(ii), (iii) (1992).3 

Heartland Hospital, located in the city of St. Joseph,

Missouri, is an acute-care facility situated fewer than 35 miles

from other hospitals. In May 1992, Heartland submitted an

application for SCH status to its Medicare fiscal intermediary,

Mutual of Omaha, in accordance with HHS regulations.4 The

intermediary recommended that the Health Care Financing
5

5

In 2002, HHS changed HCFA’s name to the “Centers for

Medicare & Medicaid Services.” See Centers for Medicare and

Medicaid Services, Statement of Organization, Functions and

Delegations of Authority, Reorganization Order, 66 Fed. Reg. 35,437

(July 5, 2001). We use “HCFA” throughout this opinion for

consistency with the prior proceedings.

Administration (HCFA),5an HHS component, deny the

application based on Heartland’s location. HCFA did so on the

ground that, because Heartland was “located in an urban area

and the closest like hospital [was] fewer than 35 miles away,” it

was ineligible under the rural location requirement. Letter from

Edward M. Brennan, HHS, to Richard G. Bath, Mutual of

Omaha (Jan. 22, 1993). 

Heartland appealed HCFA’s decision to HHS’s Provider

Reimbursement Review Board (PRRB), seeking expedited

judicial review of the denial of SCH status pursuant to 42 U.S.C.

§ 1395oo(f)(1). Under that provision, a hospital is entitled to

expedited judicial review of any determination that “involves a

question of law or regulations relevant to the matters in

controversy” that the Board “is without authority to decide.” 42

U.S.C. § 1395oo(f)(1). Because Heartland’s appeal challenged

the validity of the regulatory requirement that a hospital situated

within 35 miles of another hospital be located in a rural area,

and thereby raised “a question of law or regulations” that the

PRRB lacked authority to decide, the PRRB granted Heartland’s

request. Letter from Irvin Kues, HHS, to Christopher L.

Crosswhite, Vinson & Elkins (Mar. 29, 1995).

Heartland then filed suit in the United States District Court

for the District of Columbia, challenging the validity of the rural

location requirement on a number of grounds. The case was
6

6

Judge Greene noted two alternatives to MSAs that had been

suggested in comments during the 1983 rulemaking: “urbanized

areas,” as the term is used by the Census Bureau; and “health facility

planning areas,” as described in the National Health Planning and

Resources Development Act of 1974, Pub. L. No. 93-641, § 3, 88 Stat.

2225, 2229 (1975). 

assigned to the late Judge Harold Greene, who held that the

requirement was consistent with the Medicare statute and that

HHS had established a rational basis for adopting it. Heartland

Hospital v. Shalala (Heartland I), No. 95-951, slip op. at 15, 19

(D.D.C. June 15, 1998). But the court also found that HHS had

failed to consider reasonable alternatives proposed by

commenters when it chose an MSA-based definition of “urban

area.”6 “The failure of the Secretary to respond to reasonable

alternative[s]” to MSAs “as the relevant measure of an urban

area,” the court held, “renders the adoption of the regulations

arbitrary and capricious and, consequently, invalid.” Id. at 23-

24. The order accompanying the district court’s 1998 opinion

granted Heartland’s motion for summary judgment and

remanded the case to HHS “for action consistent with the

foregoing opinion.” Heartland I, order at 1 (June 15, 1998).

Following the district court’s decision, things did not go as

Heartland had hoped. In 1999, HHS conducted a rulemaking

regarding a number of Medicare reimbursement issues. In the

course of that rulemaking, the agency considered -- and rejected

-- the alternative definitions of “urban area” noted in Heartland

I. The agency explained why it believed that the MSA-based

definition was the better one, and announced that it would

continue to use that definition. See Changes to the Hospital
7

Inpatient Prospective Payment Systems and Fiscal Year 2000

Rates, Final Rule, 64 Fed. Reg. 41,490, 41,513-15 (July 30,

1999); Changes to the Hospital Inpatient Prospective Payment

Systems and Fiscal Year 2000 Rates, Proposed Rule, 64 Fed.

Reg. 24,716, 24,732 (May 7, 1999).

In 2000, HCFA took up the remand from Heartland I.

Once again, the agency concluded that Heartland did not qualify

for SCH status, giving three reasons. First, HCFA determined

that Heartland I did not vacate the SCH regulation, but merely

remanded the case to HHS to further explain its definition of

“urban area.” Decision of the Administrator, Heartland Hosp.

v. Blue Cross & Blue Shield Ass’n, PRRB Case No. 93-0648E,

at 21 (Sept. 6, 2000). Finding that, in the 1999 rulemaking,

HHS had “articulated a reasonable basis for the use of an MSAbased definition of rural, as opposed to other alternatives,”

HCFA concluded that “the MSA-based rural criteri[on] is

properly applied in adjudicating this case.” Id. at 27. And

because Heartland was “located in an urban area and [was]

within 35 miles of other like hospitals,” HCFA determined that

it did “not meet the applicable criteria for designation as a sole

community hospital.” Id.

Second, HCFA found that, even if the court’s order did

vacate the regulation, the district court “did not order the

payment of money to [Heartland] based on designation as a sole

community hospital,” and “did not comment on whether

[Heartland] should be designated as a sole community hospital.”

Id. At most, HCFA said, “the Court’s action affected that part

of the regulation which defines ‘rural’ within the context of

MSAs,” but “did not invalidate the rural requirement itself.” Id.

at 28. Concluding that “the establishment of a definition of

rural, through adjudication, would not constitute retroactive
8

7Specifically, HCFA said that Heartland had failed to demonstrate

“that no more tha[n] 25 percent of the residents who become hospital

inpatients or no more than 25 percent of the Medicare beneficiaries

who become hospital inpatients in the hospital’s service area are

admitted for care to other like hospitals within a 35 mile radius of the

hospital or, if larger, within its service areas [as] required by 42 C.F.R.

412.92(a)(1)(i).” Heartland Hosp., PRRB Case No. 93-0648E, at 34

(Sept. 6, 2000). 

8The district court further stayed the APA action pending

resolution of this appeal.

rulemaking,” id., HCFA determined that “the adoption of a

MSA-based rural definition is appropriate and reasonable for the

reasons” articulated in the 1999 rulemaking. Id. at 29. 

Finally, HCFA reasoned that, even if the rural requirement

were deleted from the regulation altogether, Heartland still

would not qualify for SCH status because it had failed to

demonstrate that it met the other regulatory criteria that HHS

had established for qualification under clause (II). Id.7

Heartland then returned to the district court with a twopronged attack on HCFA’s decision. First, it filed a motion to

enforce the Heartland I judgment, seeking a declaration of SCH

status as well as reimbursement and interest. Second, Heartland

filed a separate action challenging HCFA’s decision on remand

under the Administrative Procedure Act (APA), 5 U.S.C. §§

701-706. In light of the death of Judge Greene, both matters

were reassigned to another district judge. Heartland and HHS

agreed to stay the APA action pending the disposition of

Heartland’s motion to enforce the judgment.8
9

In August 2004, the district court denied that motion.

Heartland Hosp. v. Thompson (Heartland II), 328 F. Supp. 2d

8 (D.D.C. 2004). The court determined that “Judge Greene did

not intend to grant [Heartland] SCH status, reimbursement and

interest.” Id. at 15. “[A]ll that was required by the prior

judgment,” the court said, was that HHS “reconsider[] the

alternatives to” the MSA-based definition of “urban area.” Id.

Finding that HHS had reconsidered those alternatives and

“concluded that they are inferior,” the court held that Heartland

had received all the relief the judgment required. Id. Thereafter,

Heartland filed the instant appeal.

II

The parties spend the bulk of their briefs disputing whether

Judge Greene’s 1998 opinion in Heartland I vacated the rural

area requirement. Notwithstanding that the word “vacate” does

not appear in that opinion, Heartland contends that the decision

vacated the requirement by pronouncing the regulations

“invalid,” and that vacatur entitled the hospital to SCH status

and reimbursement. HHS maintains that the decision did not

vacate the rural area requirement, but merely remanded for

consideration of alternative definitions of “urban area.”

We do not need to resolve this interpretive dispute in order

to decide this case. Success on a motion to enforce a judgment

gets a plaintiff only “the relief to which [the plaintiff] is entitled

under [its] original action and the judgment entered therein.”

Watkins v. Washington, 511 F.2d 404, 406 (D.C. Cir. 1975).

Regardless of whether the district court vacated the rule, it is

clear that the Heartland I judgment does not entitle the hospital

to the remedy it seeks: a declaration of SCH status and

reimbursement. Our reasoning is set forth below.
10

A

Even if Heartland I vacated the rural area requirement,

nothing on the face of that decision compelled HHS to grant

Heartland SCH status and reimbursement. The court’s order

merely remanded the case to HHS “for action consistent with the

foregoing opinion.” Heartland I, order at 1. The “foregoing

opinion,” in turn, found the rural area requirement in the HHS

regulations invalid solely on the ground that HHS had “failed to

consider or respond to reasonable alternatives to the use of

[MSAs] as the relevant measure of an urban area,” and hence as

the definition of a rural area. Heartland I, slip op. at 24.

Accordingly, even if Heartland I vacated the rural area

requirement, the only obligation it expressly imposed on the

agency was to consider the two alternatives suggested during the

comment period.

That is precisely what the agency did. After the court

issued its decision in Heartland I, HHS considered the

alternatives and then reissued its MSA-based definition of

“urban area” and “rural area.” See 64 Fed. Reg. 24,716, 24,732

(May 7, 1999) (setting forth the proposed definition and

soliciting comments); 64 Fed. Reg. 41,490, 41,513-15 (July 30,

1999) (adopting the definition and rejecting alternatives).

Thereafter, in its decision on remand from Heartland I, HCFA

incorporated HHS’s rationale for rejecting the alternatives and

adopting the MSA-based definition. In short, the agency

complied with the judgment in Heartland I by filling the

analytical gap identified in that opinion. 

Nor did Heartland I imply that anything more was required.

It certainly did not suggest that, after considering the

alternatives, the agency was barred from reinstating the same
11

9See, e.g., FEC v. Akins, 524 U.S. 11, 25 (1998) (noting that, after

vacatur and remand, an agency “might later, in the exercise of its

lawful discretion, reach the same result for a different reason” (citing

SEC v. Chenery Corp., 318 U.S. 80 (1943))); NTEU v. FLRA, 30 F.3d

1510, 1514 (D.C. Cir. 1994) (noting that “we frequently remand

matters to agencies while leaving open the possibility that the agencies

can reach exactly the same result as long as they . . . explain

themselves better or develop better evidence for their position”).

definition or from reaching the same result through case-by-case

adjudication. To the contrary, the usual rule is that, with or

without vacatur, an agency that cures a problem identified by a

court is free to reinstate the original result on remand.9 Nothing

in Heartland I suggested that this usual rule would not apply

because, for example, the rural location requirement was

irredeemable. Rather, Judge Greene held that the requirement

was “well within the realm of permissible interpretations of” the

Medicare statute, Heartland I, slip op. at 15, that “the Secretary

[had] established . . . a rational basis for the . . . requirement,” id.

at 19, and that it was “plausible . . . that [MSAs] are a valid

measure of urban areas,” id. at 23. 

This is not to say, of course, that the agency’s reaffirmation

of the same result in this case is invulnerable to attack on a

ground other than the agency’s failure to consider reasonable

alternatives -- for example, on the ground that the agency

arbitrarily rejected those alternatives. See Motor Vehicles

Mfrs. Ass’n v. StateFarm Mut. Auto. Ins. Co., 463 U.S. 29, 43,

48, 56 (1983). But whether or not the agency’s post-Heartland

I rejection of the alternatives was arbitrary is a determination

that must be made in Heartland’s separate APA action

challenging HHS’s post-remand decisions. Nothing in

Heartland I itself addresses that question, and therefore a motion
12

to enforce the Heartland I judgment is not the proper means to

answer it.

The same is true for Heartland’s oblique suggestion that if

Judge Greene vacated the rural area requirement, then HHS’s

attempt to reimpose the requirement on remand -- whether

through rulemaking or adjudication -- effectively constituted

impermissible retroactive rulemaking. See Appellant’s Reply

Br. at 2 n.1; see also Bowen v. Georgetown Univ. Hosp., 488

U.S. 204, 215 (1988) (holding that HHS “has no authority to

promulgate retroactive cost-limit rules” under the Medicare

Act). Our cases establish a five-factor “framework for

evaluating retroactive application of rules announced in agency

adjudications.” Cassell v. FCC, 154 F.3d 478, 486 (D.C. Cir.

1998) (quotingClark-Cowlitz Joint Operating Agency v. FERC,

826 F.2d 1074, 1081 (D.C. Cir. 1987) (en banc)). Nothing in

Heartland I indicates whether HCFA’s adjudicatory application

of the rural requirement would survive examination under that

framework. Accordingly, that, too, is a determination that must

await disposition of Heartland’s separate APA action. 

B

Heartland contends that, even if the face of Heartland I did

not require HHS to grant the hospital SCH status, vacation of the

rural area requirement would have “eliminat[ed] the only

remaining barrier to SCH status for Heartland.” Appellant’s Br.

at 14. That is so, the hospital maintains, because “[u]nder the

applicable statute and regulations, the [PRRB] can grant

expedited judicial review only if it first determines that there are

no disputed issues of fact and no disputed legal issues that the

Board is authorized to resolve.” Id. at 14-15. Thus, Heartland

insists, by granting its request for expedited review, the PRRB
13

10See Letter from Linda Richter, Mutual of Omaha, to Christopher

Crosswhite, Vinson & Elkins, at 2-3 (Feb. 1, 1994) (“HCFA’s denial

of SCH status was based on [Heartland] being located in an urban

area with like hospitals located closer than 35 miles. . . . HCFA has

made no determination as to whether [Heartland] met all criteria other

than being located in a rural area.”).

“necessarily determined that Heartland had met all the statutory

and regulatory criteria to obtain SCH status and that the only

remaining question was the validity of [HHS’s] rural

requirement.” Id. at 21. 

There are two problems with this argument. First, even if

Heartland is correct that at the time of Heartland I the rural area

requirement was the only hurdle still standing between it and

SCH status, the judgment did not say so. Even if the agency had

implicitly decided prior to Heartland I that the hospital met all

the other SCH criteria, at best that would mean the post-remand

denial was inconsistent with those implicit findings. And while

such inconsistency might justify a court in concluding that

HCFA’s post-Heartland I denial of the hospital’s SCH status

was arbitrary and capricious (and thus in violation of the APA),

that is a conclusion Judge Greene did not reach in Heartland I

itself.

The second -- and more significant -- problem with

Heartland’s argument is that it reads too much into the PRRB’s

expedited judicial review determination. In denying Heartland

SCH status, both HCFA and the intermediary relied solely on

the hospital’s failure to satisfy the regulation’s rural location

requirement. Neither considered whether there might be other

reasons for denial; neither said that, but for the regulation, the

hospital’s application would have been granted.10 Similarly,
14

when Heartland asked the PRRB to grant expedited review, it

emphasized that “the sole basis for its appeal of HCFA’s denial

is that the regulatory requirement of location in a rural area is

invalid.” Provider’s Request for Expedited Judicial Review,

Heartland Hosp. v. Mutual of Omaha Ins. Co., PRRB Case No.

93-0648, at 10-11 (Mar. 6, 1995). And when the PRRB granted

Heartland’s request, it did so on the ground that it was “without

authority to decide the legal question of whether the Medicare

regulation governing the classification as a sole community

hospital . . . is valid.” Letter from Kues to Crosswhite at 2.

Nor is Heartland correct that the statute and regulation

required the PRRB to decide every factual and legal question

within its power -- including those on which the intermediary

did not rely in recommending denial of Heartland’s SCH status

-- before it could grant expedited review regarding the validity

of the legal ground on which the intermediary did rely. The

statute itself states only that health care providers “have the right

to obtain judicial review of any action of the fiscal intermediary

which involves a question of law or regulations relevant to the

matters in controversy whenever the Board determines . . . that

it is without authority to decide the question.” 42 U.S.C. §

1395oo(f)(1). Here, the intermediary’s denial of Heartland’s

application on the basis of the rural location requirement plainly

involved “a question of law or regulations,” that was “relevant

to the matters in controversy,” and that the PRRB was “without

authority to decide.” See Bethesda Hosp. Ass’n v. Bowen, 485

U.S. 399, 406 (1988) (“Neither the fiscal intermediary nor the

Board has the authority to declare regulations invalid.”). Thus,

Heartland’s appeal fell squarely within the expedited review
15

1 1Although Heartland correctly notes that “the Board can ‘make

any other revisions on matters covered by [a] cost report . . . even

though such matters were not considered by the intermediary in

making such final determination,’” Bethesda Hosp. Ass’n v. Bowen,

485 U.S. 399, 405-06 (1988) (quoting 42 U.S.C. § 1395oo(d))

(emphasis added), the statute does not compel the Board to do so, see

42 U.S.C. § 1395oo(d) (“The Board shall have the power to [consider]

matters . . . not considered by the intermediary.” (emphasis added)).

12See 42 C.F.R. § 405.1842(g)(2) (“The Board has the authority

to decide when two or more issues are sufficiently related to preclude

separation for purposes of an expedited review determination on one

or more of them and a hearing on the other or others.”); id. §

405.1842(h)(6) (“The Board’s determination [to grant expedited

judicial review] does not affect the right of the provider to a Board

hearing for issues for which the provider did not request expedited

review, or for which the Board determines it does have the authority

to decide, or for which the Board did not make a determination and the

provider did not request judicial review.”).

provision of the statute whether or not Heartland met the other

SCH criteria.11

The HHS regulation that governs expedited review similarly

permits expedition if there are no “factual or legal issues in

dispute on an issue within the authority of the Board to decide.”

42 C.F.R. § 405.1842(g)(2) (emphasis added). The regulation

does not suggest that the PRRB is barred from granting

expedited review unless it first decides all factual questions

within its competence, including those regarding other issues not

relied upon by HCFA or the intermediary. Indeed, the

regulatory language is to the contrary.12 As Heartland stresses,

HHS did state at the time the regulation was promulgated that

the statute’s expedited judicial review provision “authorizes the
16

13Tucson Medical Center v. Sullivan, 947 F.2d 971 (D.C. Cir.

1991), is not to the contrary. In Tucson, we stated in dictum that, by

granting petitions for expedited review, the PRRB had “necessarily

found that there existed an amount in controversy in excess of

$10,000” because “the PRRB does not have jurisdiction to hear an

appeal from the fiscal intermediary’s determination unless ‘the amount

in controversy is $10,000 or more.’” Id. at 980 (quoting 42 U.S.C. §

1395oo(a)(2)). Although the statute expressly predicates PRRB

jurisdiction on a $10,000 amount in controversy, it does not -- as

discussed above -- predicate jurisdiction or anything else upon the

resolution of every possible alternative basis for denial of a hospital’s

SCH application.

bypassing of the required Board hearing only with respect to

those matters in dispute for which the sole issue to be resolved

is the validity of the law, regulations, or HCFA rulings which

the Board cannot decide.” Appellant’s Br. at 7 (quoting

Provider Reimbursement Review Board, Expedited

Administrative Review, Final Rule, 48 Fed. Reg. 22,920, 22,922

(May 23, 1983)) (emphasis added in Appellant’s Br.). But in

this instance, the sole issue to be resolved -- because it was the

sole basis for Heartland’s appeal -- was the validity of the rural

location requirement, an issue that involved no factual or legal

issues within the Board’s competence.

In sum, both the statute and the regulation permitted the

Board to grant expedited review regarding the validity of the

rural location requirement without first deciding all other

possible bases for denying Heartland SCH status -- none of

which were addressed by the intermediary, by HCFA, or by

Heartland. Hence, in granting expedited review, the Board did

not determine -- “necessarily” or otherwise -- that Heartland had

met all the statutory and regulatory criteria for such status.13
17

III

For the foregoing reasons, we conclude that, regardless of

whether the district court intended to vacate the rural area

requirement in Heartland I, the court’s judgment did not entitle

Heartland Hospital to the relief it seeks on this appeal. What the

judgment did require was what Heartland received -- HHS’s

reconsideration of the alternatives to the MSA-based definition

of “urban area.” Accordingly, if Heartland is to obtain further

relief, it must seek it through a separate APA challenge to

HCFA’s post-Heartland I decisions, rather than through a

motion to enforce the Heartland I judgment itself. The district

court’s denial of Heartland’s motion is therefore 

Affirmed.