Skip to main content


U.S. flag
      An official website of the United States government
              Here’s how you know
        Here’s how you knowDot gov**Official websites use .gov**
                 A **.gov** website belongs to an official government organization in the United States.
                  HTTPS**Secure .gov websites use HTTPS**
                 A **lock** (A locked padlock) or **https://** means you’ve safely connected to the .gov website. Share sensitive information only on official, secure websites. 
  Menu Close
          HHS Search block
    Search
        








  
  
    

  
      

                                      About HHS
    
                        
                              
      
      
      Programs & Services
    
                        
                              
      
      
      Grants & Contracts
    
                        
                              
      
      
      Laws & Regulations Breadcrumb
    Home
                              About
                              Agencies
                              DAB
                              Decisions
                              ALJ Decisions
                              2019
                              In re CMS LCD Complaint: Ambulance Service, Basic Life Support, Non-Emergency Transport, DAB CR5354 (2019)
 Navigate to:
  Departmental Appeals Board (DAB)
    
                                                  
                                                    
            
      
      
      
      About DAB
                                            
            
            Organizational Overview
    
                                                  
                              
            
      
      
      
      Who are the Judges?
    
                                                  
                              
            
      
      
      
      DAB Divisions
    
                                                  
                              
            
      
      
      
      Contact DAB
    
                                                  
                                                    
            
      
      
      
      Filing an Appeal Online
                                            
            
            DAB E-File
    
                                                  
                              
            
      
      
      
      Medicare Operations Division (MOD) E-File
    
                                                  
                                                    
            
      
      
      
      Different Appeals at DAB
                                            
            
            Appeals to DAB Administrative Law Judges (ALJs)
                          
            
            Forms
    
                                                  
                              
            
      
      
      
      Procedures
    
                                                                
                                                    
            
      
      
      
      Appeals to Board
                          
            
            Practice Manual
    
                                                  
                              
            
      
      
      
      Guidelines
    
                                                  
                              
            
      
      
      
      Regulations
    
                                                  
                              
            
      
      
      
      National Coverage Determination Complaints
    
                                                                
                                                    
            
      
      
      
      Appeals to the Medicare Appeals Council (Council)
                          
            
            Forms
    
                                                  
                              
            
      
      
      
      Fully Integrated Duals Advantage (FIDA) Demonstration Project
    
                                                  
                                                    
            
      
      
      
      Alternative Dispute Resolution Services
                                            
            
            Sharing Neutrals
    
                                                  
                              
            
      
      
      
      ADR Training
    
                                                  
                              
            
      
      
      
      Other ADR Services
    
                                                  
                                                    
            
      
      
      
      DAB Decisions
                                            
            
            Board Decisions
    
                                                  
                              
            
      
      
      
      DAB Administrative Law Judge (ALJ) Decisions
    
                                                  
                              
            
      
      
      
      Medicare Appeals Council (Council) Decisions
    
                                    
                              
            
      
      
      
      Stakeholder Feedback
    
                                                  
                                                    
            
      
      
      
      Careers
                                            
            
            Open Career Opportunities
    
                                                  
                              
            
      
      
      
      Internships & ExternshipsText resize icon

                    




In re CMS LCD Complaint: Ambulance Service, Basic Life Support, Non-Emergency Transport, DAB CR5354 (2019)








  
  
    

  
      
Department of Health and Human Services 
    DEPARTMENTAL APPEALS BOARD
          Civil Remedies Division





*In re CMS LCD Complaint:*
	Ambulance Service, Basic Life Support,
	Non-Emergency Transport
Docket No. C-19-679Decision No. CR5354June 24, 2019

        
              
    

      DECISION DISMISSING UNACCEPTABLE COMPLAINT
The Civil Remedies Division received correspondence on April 15, 2019, from Julie Carter Mayville, the appointed representative of William Aubrey Carter (Aggrieved Party), which was treated as a challenge to a local coverage determination (LCD), docketed as styled above, C-19-679, and assigned to me for review.
The regulations at 42 C.F.R. § 426.410(b) require that I determine whether an aggrieved party has filed an “acceptable” and “valid” complaint. After reviewing the documents submitted, I concluded that they did not constitute an acceptable and valid LCD complaint under the applicable regulations. Therefore, in an Acknowledgment of Receipt and Order to Aggrieved Party to Amend Unacceptable Complaint (Order), dated April 29, 2019, I informed the Aggrieved Party’s representative that she had one opportunity to submit an acceptable complaint. *See*42 C.F.R. § 426.410(c)(1).
My April 29 Order listed the information that is required to be included in an LCD complaint to make it acceptable. I specifically directed the Aggrieved Party’s representative to provide all of the following information:
*Timeliness of complaint:*As I explained in detail in my April 29 Order, I was unable to determine whether the unacceptable complaint had been timely filed. I therefore directed the Aggrieved Party’s representative to submit a copy of the initial notice denying payment for the service at issue.Page 2
*LCD-identifying information:*As I explained in detail in my April 29 Order, I was unable to determine whether the unacceptable complaint was challenging an LCD or a determination by CMS that the requested service does not fall within the statutory benefit category of ambulance services. I therefore directed the Aggrieved Party’s representative to provide (i) the name of the contractor using the LCD; (ii) the title of the LCD; and (iii) the specific provision of the LCD that adversely affects the Aggrieved Party.
	*Treating physician written statement:*The unacceptable complaint did not include a copy of a written statement from the treating physician that the Aggrieved Party needs the service that is the subject of the LCD. I therefore directed the Aggrieved Party’s representative to submit such documentation in the form of a written order or other documentation from the Aggrieved Party’s medical record indicating that the Aggrieved Party needs the service.
	*Aggrieved Party statement:*The unacceptable complaint explained what service the Aggrieved Party needs, but it did not explain why the Aggrieved Party contends that the provision(s) of the LCD is (are) not valid under the reasonableness standard. I therefore directed the Aggrieved Party’s representative to submit a statement explaining the Aggrieved Party’s position.
	*Clinical or scientific evidence:*The unacceptable complaint did not include copies of clinical or scientific evidence in support of the Aggrieved Party’s position. Nor did it include an explanation of why the clinical or scientific evidence shows that the LCD is not reasonable. I therefore directed the Aggrieved Party’s representative to submit such evidence and argument.My April 29 Order directed the Aggrieved Party’s representative to file an amended complaint within 30 days of the date of the Order. I advised the Aggrieved Party’s representative that if she did not submit an acceptable amended complaint, then I must issue a decision dismissing the unacceptable complaint. 42 C.F.R. § 426.410(c)(2).
More than 30 days have passed since I issued the April 29 Order and the Aggrieved Party’s representative has not filed a response amending the complaint. Therefore, for the reasons explained in that Order, the complaint received on April 15, 2019 remains unacceptable under 42 C.F.R. § 426.410(b). I am required to dismiss the unacceptable complaint. 42 C.F.R. § 426.410(c)(2). Accordingly, I order that the complaint be dismissed.
  
          /s/
        Leslie A. Weyn

                      Administrative Law Judge Back to top
    Contact HHS
    
                        
                                            
      
      
      Careers
    
                        
                                            
      
      
      HHS FAQs
    
                        
                                            
      
      
      Nondiscrimination NoticeHHS Archive
    
                        
                                            
      
      
      Accessibility Statement
    
                        
                                            
      
      
      Privacy Policy
    
                        
                                            
      
      
      Viewers & PlayersBudget/Performance
    
                        
                                            
      
      
      Inspector General
    
                        
                                            
      
      
      Web Site Disclaimers
    
                        
                                            
      
      
      EEO/No Fear ActFOIA
    
                        
                                            
      
      
      The White House
    
                        
                                            
      
      
      USA.gov
    
                        
                                            
      
      
      Vulnerability Disclosure Policy
        Sign Up for Email Updates

Receive the latest updates from the Secretary, Blogs, and News Releases.

Sign Up
  HHS Headquarters
          200 Independence Avenue, S.W.
                  Washington, D.C. 20201
                  Toll Free Call Center: 1-877-696-6775​ Disclaimer Policy: Links with this icon () mean that you are leaving the HHS website. The Department of Health and Human Services (HHS) cannot guarantee the accuracy of a non-federal website.
                  Linking to a non-federal website does not mean that HHS or its employees endorse the sponsors, information, or products presented on the website. HHS links outside of itself to provide you with further information.
                  You will be bound by the destination website's privacy policy and/or terms of service when you follow the link.
                  HHS is not responsible for Section 508 compliance (accessibility) on private websites. For more information on HHS's web notification policies, see Website Disclaimers.
 Continue
                  Go back