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Matched Legal Cases: ['§ 405', '§ 405', '§ 1331', '§ 405', '§ 1331', '§ 1361', '§ 405', '§ 405', '§ 405', '§ 405', '§ 405', '§ 1361', '§ 405', '§ 405', '§ 405', '§ 1395', '§ 1395', '§ 1395', '§ 1395', '§ 405', '§ 1395', '§ 1395', '§ 405', '§ 1395', '§ 405', '§ 405', '§ 1395', '§ 405', '§ 405', '§ 404', '§ 1395', '§ 1331', '§ 1361', '§ 405', '§ 405', '§ 405', '§ 405', '§ 405', '§ 1395', '§ 405', '§ 1331', '§ 405', '§ 405', '§ 405', '§ 405', '§ 1361', '§ 1651', '§ 405', '§ 405', '§ 1331', '§ 1331', '§ 1395', '§ 405', '§ 405', '§ 405', '§ 405', '§ 1331', '§ 405', '§ 405', '§ 405', '§ 405', '§ 405', '§ 1331', '§ 405', '§ 405', '§ 405', '§ 405', '§ 1862', '§ 205', '§ 1331', '§ 1331', '§ 205', '§ 205', '§ 205', '§ 205', '§ 1869', '§ 205', '§ 205', '§ 1872', '§ 205', '§ 205', '§ 1872', '§ 205', '§ 1869', '§ 205', '§ 205', '§ 701', '§ 1331', '§ 205', '§ 1331', '§ 205', '§ 205', '§ 205', '§ 205', '§ 205', '§ 205', '§ 205', '§ 205', '§ 205', '§ 205', '§ 205', '§ 205', '§ 205', '§ 205', '§ 205', '§ 702', '§ 701', '§ 704', '§ 205', '§ 205']

Heckler v. Ringer :: 466 U.S. 602 (1984) :: Justia U.S. Supreme Court Center Log In
› Heckler v. Ringer
Heckler v. Ringer 466 U.S. 602 (1984)
U.S. Supreme CourtHeckler v. Ringer, 466 U.S. 602 (1984)Heckler v. RingerNo. 82-1772Argued February 27, 1984Decided May 14, 1984466 U.S. 602CERTIORARI TO THE UNITED STATES COURT OF APPEALS
Part A of Title XVIII of the Social Security Act, commonly known as the Medicare Act, provides insurance for the cost of hospital and related post-hospital expenses, but precludes reimbursement for services which are not "reasonable and necessary" for the diagnosis or treatment of illness or injury. Judicial review of a claim under the Medicare Act is available only after the Secretary of Health and Human Services renders a "final decision" on the claim in the same manner as is provided in 42 U.S.C. § 405(g) for old-age and disability claims arising under Title II of the Social Security Act. Title 42 U.S.C. § 405(h), to the exclusion of 28 U.S.C. § 1331 (federal question jurisdiction), makes § 405(g) the sole avenue for judicial review of all "claim[s] arising under" the Medicare Act. Pursuant to her rulemaking authority, the Secretary has provided that a "final decision" is rendered on a Medicare claim only after the claimant has pressed the claim through all designated levels of administrative review. In January, 1979, the Secretary issued an administrative instruction to all fiscal intermediaries that no payment is to be made for Medicare claims arising out of a surgical procedure known as bilateral carotid body resection (BCBR) when performed to relieve respiratory distress. Until October, 1980, Administrative Law Judges (ALJs), who were not bound by the instruction, consistently ruled in favor of claimants whose BCBR claims had been denied by the intermediaries. The Appeals Council also authorized payment for BCBR Part A expenses in a case involving numerous claimants. On October 28, 1980, the Secretary issued a formal administrative ruling, intended to have a binding effect on the ALJs and the Appeals Council, prohibiting them from ordering Medicare payments for BCBR operations occurring after that date, the Secretary having concluded that the BCBR procedure was not "reasonable and necessary" within the meaning of the Medicare Act. Without having exhausted their administrative remedies, respondents brought an action in Federal District Court challenging the Secretary's instruction and ruling, and relying on 28 U.S.C. § 1331, 28 U.S.C. § 1361 (mandamus against federal official), and 42 U.S.C. § 405(g) to establish jurisdiction. Respondents are four Medicare claimants for whom BCBR surgery was prescribed to relieve pulmonary problems. Three of the respondents (Holmes, Webster-Zieber, and Vescio) had the surgery before Page 466 U. S. 603 October 28, 1980, and filed claims for reimbursement with the fiscal intermediary, and the fourth respondent (Ringer) never had the surgery, claiming that he was unable to afford it. The complaint sought a declaration that the Secretary's refusal to find that BCBR surgery is "reasonable and necessary" under the Medicare Act is unlawful, and an injunction compelling her to instruct her intermediaries to provide payment for BCBR claims and barring her from forcing claimants to pursue administrative appeals in order to obtain payment. The District Court dismissed the complaint for lack of jurisdiction, holding that, in essence, respondents were claiming entitlement to benefits for the BCBR procedure, that any challenges to the Secretary's procedure were "inextricably intertwined" with respondents' claim for benefits, and that therefore respondents must exhaust their administrative remedies pursuant to § 405(g) before pursuing their action in federal court. The Court of Appeals reversed, holding that, to the extent respondents were seeking to invalidate the Secretary's procedure for determining entitlement to benefits, those claims were cognizable under the federal question and mandamus statutes, without the administrative exhaustion requirement of § 405(g). While acknowledging that § 405(g), with its exhaustion requirement, provides the only jurisdictional basis for seeking judicial review of claims for benefits, the court nonetheless held that the District Court erred in requiring respondents to exhaust their administrative remedies, since exhaustion would be futile and might not fully compensate respondents for their asserted injuries in view of the fact that they sought payment without the prejudice -- and the necessity of appeal -- resulting from the existence of the Secretary's instruction and ruling.
(b) Assuming without deciding that § 405(h) does not foreclose mandamus jurisdiction in all Social Security Act cases, the District Court did not err in dismissing respondents' complaint, because no writ of mandamus could properly issue. Title 28 U.S.C. § 1361 is intended to provide a remedy only if the plaintiff has exhausted all other avenues of Page 466 U. S. 604 relief, and only if the defendant owes him a nondiscretionary duty. Here, the above respondents clearly have an adequate remedy under § 405(g) for challenging all aspects of the Secretary's denial of their claims, and thus § 405(g) is the only avenue for judicial review of their claims. While these respondents satisfied the nonwaivable requirement of presenting a claim to the Secretary, they did not satisfy the waivable requirement that administrative remedies be exhausted. Pp. 466 U. S. 616-619.
REHNQUIST, J., delivered the opinion of the Court, in which BURGER, C.J., and WHITE, BLACKMUN, POWELL, and O'CONNOR, JJ., joined. STEVENS, J., filed an opinion concurring in the judgment in part and dissenting in part, in which BRENNAN and MARSHALL, JJ., joined, post, p. 466 U. S. 627.
Respondents are individual Medicare claimants who raise various challenges to the policy of the Secretary of Health and Human Services (Secretary) as to the payment of Medicare Page 466 U. S. 605 benefits for a surgical procedure known as bilateral carotid body resection (BCBR). The United States District Court for the Central District of California dismissed the action for lack of jurisdiction, finding that, in essence, respondents are claiming entitlement to benefits for the BCBR procedure, and therefore must exhaust their administrative remedies pursuant to 42 U.S.C. § 405(g) before pursuing their action in federal court. The Court of Appeals for the Ninth Circuit reversed and remanded for consideration on the merits. 697 F.2d 1291 (1982). We granted certiorari to sort out the thorny jurisdictional problems which respondents' claims present, 463 U.S. 1206 (1983), and we now reverse as to all respondents.
Title XVIII of the Social Security Act, 79 Stat. 291, as amended, 42 U.S.C. § 1395 et seq., commonly known as the Medicare Act, establishes a federally subsidized health insurance program to be administered by the Secretary. Part A of the Act, 42 U.S.C. § 1395c et seq., provides insurance for the cost of hospital and related post-hospital services, but the Act precludes reimbursement for any "items or services . . . which are not reasonable and necessary for the diagnosis or treatment of illness or injury." § 1395y(a)(1). The Medicare Act authorizes the Secretary to determine what claims are covered by the Act "in accordance with the regulations prescribed by him." § 1395ff(a). Judicial review of claims arising under the Medicare Act is available only after the Secretary renders a "final decision" on the claim, in the same manner as is provided in 42 U.S.C. § 405(g) [Footnote 1] for old age and disability claims arising under Title II of the Social Security Act. 42 U.S.C. § 1395ff(b)(1)(C). Page 466 U. S. 606
Pursuant to her rulemaking authority, see 42 U.S.C. §§ 1395hh, 1395ii (incorporating 42 U.S.C. § 405(a)), the Secretary has provided that a "final decision" is rendered on a Medicare claim only after the individual claimant has pressed his claim through all designated levels of administrative review. [Footnote 2] First, the Medicare Act authorizes the Secretary to enter into contracts with fiscal intermediaries providing that the latter will determine whether a particular medical service is covered by Part A, and if so, the amount of the reimbursable expense for that service. 42 U.S.C. § 1395h; 42 CFR § 405.702 (1983). If the intermediary determines that a particular service is not covered under Part A, the claimant can seek reconsideration by the Health Care Financing Administration (HCFA) in the Department of Health and Human Services. 42 CFR §§ 405.710-405.716 (1983). If denial of the claim is affirmed after reconsideration, and if the claim exceeds $100, the claimant is entitled to a hearing before an administrative law judge (ALJ) in the same manner as is provided for claimants under Title II of the Act. 42 U.S.C. §§ 1395ff(b)(1)(C), (b)(2); 42 CFR § 405.720 (1983). Page 466 U. S. 607 If the claim is again denied, the claimant may seek review in the Appeals Council. 42 CFR §§ 405.701(c), 405.724 (1983) (incorporating 20 CFR § 404.967 (1983)). If the Appeals Council also denies the claim and if the claim exceeds $1,000, only then may the claimant seek judicial review in federal district court of the "Secretary's final decision." 42 U.S.C. §§ 1395ff(b)(1)(C), (b)(2).
Many claimants whose BCBR claims were denied by the intermediaries as a result of the instruction sought review of the denial before ALJs, who were not bound by the Secretary's instructions to the intermediaries. Until October, Page 466 U. S. 608 1980, ALJs were consistently ruling in favor of individual BCBR claimants. The Appeals Council also authorized payment for BCRB Part A expenses in a consolidated case involving numerous claimants, see In re Ferguson, No. 12612-3830 (HHS Appeals Council, Oct. 18, 1979), while stressing that its decision applied only to the claimants involved in that case, and was not to be cited as precedent in future cases.
On September 18, 1980, respondents in this case filed a complaint in the District Court for the Central District of California, raising numerous challenges focused on the Secretary's January, 1979, instructions to her intermediaries precluding payment for BCBR surgery. [Footnote 4] On November 7, 1980, Page 466 U. S. 609 after the Secretary issued the formal ruling binding on the ALJs and the Appeals Council as well as the intermediaries, respondents amended their complaint to challenge that ruling as well. Respondents relied on 28 U.S.C. § 1331 (federal question), 28 U.S.C. § 1361 (mandamus against a federal official), and 42 U.S.C. § 405(g) (Social Security Act), to establish jurisdiction in the District Court.
The individuals named in the amended complaint, who are respondents before this Court, [Footnote 5] are four individual Medicare claimants. Their physician, Dr. Benjamin Winter, [Footnote 6] who has developed a special technique for performing BCBR surgery and who has performed the surgery over 1,000 times, prescribed BCBR surgery for all four respondents to relieve their pulmonary problems. Respondents Sanford Holmes, Norman Webster-Zieber, and Jean Vescio had the surgery before October 28, 1980, and all three filed a claim for reimbursement with their fiscal intermediary. At the time Page 466 U. S. 610 that the amended complaint was filed, none of the three had exhausted their administrative remedies, and thus none had received a "final decision" on their claims for benefits from the Secretary. The fourth respondent, Freeman Ringer, informally inquired of the Secretary and learned that BCBR surgery is not covered under the Medicare Act. Thus, he has never had the surgery, claiming that he is unable to afford it. App. 32.
The essence of their amended complaint is that the Secretary has a constitutional and statutory obligation to provide payment for BCBR surgery because overwhelmingly her ALJs have ordered payment when they have considered individual BCBR claims. Id. at 9-10. According to the complaint, the Secretary's instructions to the contrary to her intermediaries violate constitutional due process and numerous statutory provisions in that they force eligible Medicare claimants who have had BCBR surgery to pursue individual administrative appeals in order to get payment, even though ALJs overwhelmingly have determined that payment is appropriate. Id. at 16-22. Regarding the Secretary's formal administrative ruling, the complaint asserts that the ruling merely reaffirms the instructions and creates an "additional administrative barrier" to Medicare beneficiaries desiring the BCBR treatment, and that it also is unlawful on numerous substantive and procedural grounds. Id. at 23-25. [Footnote 7] The Page 466 U. S. 611 complaint seeks a declaration that the Secretary's refusal to find that BCBR surgery is "reasonable and necessary" under the Act is unlawful, an injunction compelling the Secretary to instruct her intermediaries to provide payment for BCBR claims, and an injunction barring the Secretary from forcing claimants to pursue individual administrative appeals in order to obtain payment. Id. at 9-10, 25-27.
The District Court dismissed the complaint in its entirety for lack of jurisdiction. [Footnote 8] It concluded that "[t]he essence of [respondents' claim] . . . is a claim of entitlement [to] benefits for the BCBR procedure," and that any challenges respondents raise to the Secretary's procedures are "inextricably intertwined" with their claim for benefits. App. to Pet. for Cert. 14a. Thus the court concluded that 42 U.S.C. § 405(g), with its administrative exhaustion prerequisite, provides the sole avenue for judicial review. Relying on our decision in Mathews v. Eldridge, 424 U. S. 319, 424 U. S. 330-332 (1976), the court concluded that none of respondents' claims are so "collateral" to their overall claim for benefits that the Page 466 U. S. 612 exhaustion requirement should be waived as to those claims. Because none of the named respondents have satisfied the exhaustion prerequisite of § 405(g), the court dismissed the complaint.
The Court of Appeals agreed with the District Court that respondents also had raised substantive claims for benefits, in that they had sought an injunction requiring the Secretary to declare that BCBR is reasonable and necessary under the Act. In the Court of Appeals' view, the fact that respondents had not sought an actual award of benefits in their complaint did not alter the court's characterization of a portion of their claim as essentially a claim for benefits. Ibid. Acknowledging that § 405(g) with its exhaustion prerequisite provides the only jurisdictional basis for seeking judicial review of claims for benefits, the court nonetheless concluded that the District Court had erred in requiring respondents to exhaust their administrative remedies in this case. Relying on our opinions in Weinberger v. Salfi, 422 U. S. 749 (1975), and Mathews v. Eldridge, supra, the Court of Appeals concluded that exhaustion would be futile for respondents, and that it may not fully compensate them for the injuries they assert because they seek payment without the prejudice -- and the necessity of appeal -- resulting from the existence of the instructions and the rule. 697 F.2d at 1294-1296. Because we disagree with the Court of Appeals' characterization Page 466 U. S. 613 of the claims at issue in this case and its reading of our precedents, we now reverse.
Preliminarily, we must point out that, although the Court of Appeals seemed not to have distinguished them, there are in fact two groups of respondents in this case. Respondents Holmes, Vescio, and Webster-Zieber constitute one group of respondents, those who have had BCBR surgery before October 28, 1980, and who have requested reimbursement at some, but not all, levels of the administrative process. Although the Court of Appeals did not seem to realize it, there is no dispute that the Secretary's formal administrative ruling simply does not apply to those three respondents' claims for reimbursement for their BCBR surgery. [Footnote 9] Their claims only make sense then if they are understood as challenges to the Secretary's instructions to her intermediaries, instructions which resulted in those respondents' having to pursue administrative remedies in order to get payment. They have standing to challenge the formal ruling as well only because, construing their complaint liberally, they argue that the existence of the formal rule creates a presumption Page 466 U. S. 614 against payment of their claims in the administrative process, even though the rule does not directly apply to bar their claims. The relief respondents request is that the Secretary change her policy so as to allow payment for BCBR surgery so that respondents simply will not have to resort to the administrative process.
The third sentence of 42 U.S.C. § 405(h), [Footnote 10] made applicable to the Medicare Act by 42 U.S.C. § 1395ii, provides Page 466 U. S. 615 that § 405(g), to the exclusion of 28 U.S.C. § 1331, is the sole avenue for judicial review for all "claim[s] arising under" the Medicare Act. See Weinberger v. Salfi, supra, at 422 U. S. 760-761. Thus, to be true to the language of the statute, the inquiry in determining whether § 405(h) bars federal question jurisdiction must be whether the claim "arises under" the Act, not whether it lends itself to a "substantive," rather than a "procedural," label. See Mathews v. Eldridge, 424 U.S. at 424 U. S. 327 (recognizing that federal question jurisdiction is barred by 42 U.S.C. § 405(h) even in a case where claimant is challenging the administrative procedures used to terminate welfare benefits).
Under that broad test, we have no trouble concluding that all aspects of respondents Holmes', Vescio's, and Webster-Zieber's challenge to the Secretary's BCBR payment policy "aris[e] under" the Medicare Act. It is of no importance that respondents here, unlike the claimants in Weinberger v. Salfi, sought only declaratory and injunctive relief, and not an actual award of benefits as well. Following the declaration which respondents seek from the Secretary -- that BCBR surgery is a covered service -- only essentially ministerial details will remain before respondents would receive reimbursement. Page 466 U. S. 616 Had our holding in Weinberger v. Salfi turned on the fact that claimants there did seek retroactive benefits, we might well have done as the dissent in that case suggested, and held that § 405(h) barred federal question jurisdiction only over claimants' specific request for benefits, and not over claimants' declaratory and injunctive claims as well. See 422 U.S. at 422 U. S. 798-799, and n. 13 (BRENNAN, J., dissenting). Thus we hold that the Court of Appeals erred in concluding that any portion of Holmes', Vescio's, or Webster-Zieber's claims here can be channeled into federal court by way of federal question jurisdiction.
Assuming without deciding that the third sentence of § 405(h) does not foreclose mandamus jurisdiction in all Social Security cases, see generally Dietsch v. Schweiker, 700 F.2d 865, 867-868 (CA2 1983); Ellis v. Blum, 643 F.2d 68, 78-82 (CA2 1981), the District Court did not err in dismissing respondents' complaint here, because it is clear that no writ of mandamus could properly issue in this case. The common law writ of mandamus, as codified in 28 U.S.C. § 1361, is intended to provide a remedy for a plaintiff only if he has exhausted all other avenues of relief, and only if the defendant owes him a clear nondiscretionary duty. See Kerr v. United Page 466 U. S. 617 States District Court, 426 U. S. 394, 426 U. S. 402-403 (1976) (discussing 28 U.S.C. § 1651); United States ex rel. Girard Trust Co. v. Helvering, 301 U. S. 540, 301 U. S. 543-544 (1937).
Respondents urge us to hold them excused from further exhaustion, and to hold that the District Court could have properly exercised jurisdiction over their claims under § 405(g). We have held that the Secretary herself may waive the exhaustion requirement when she deems further exhaustion futile, Mathews v. Diaz, 426 U. S. 67, 426 U. S. 76-77 (1976); Page 466 U. S. 618 Weinberger v. Salfi, 422 U.S. at 422 U. S. 766-767. We have also recognized that, in certain special cases, deference to the Secretary's conclusion as to the utility of pursuing the claim through administrative channels is not always appropriate. We held that Mathews v. Eldridge, supra, at 424 U. S. 330-332, was such a case, where the plaintiff asserted a procedural challenge to the Secretary's denial of a pretermination hearing, a claim that was wholly "collateral" to his claim for benefits, and where he made a colorable showing that his injury could not be remedied by the retroactive payment of benefits after exhaustion of his administrative remedies.
The latter exception to exhaustion is inapplicable here where respondents do not raise a claim that is wholly "collateral" to their claim for benefits under the Act, and where they have no colorable claim that an erroneous denial of BCBR benefits in the early stages of the administrative process will injure them in a way that cannot be remedied by the later payment of benefits. And here, it cannot be said that the Secretary has in any sense waived further exhaustion. In the face of the Secretary's vigorous disagreement, the Court of Appeals concluded that the Secretary's formal ruling denying payment for BCBR claims rendered further exhaustion by respondents futile. But as we have pointed out above, the administrative ruling is not even applicable to respondents' claims, because they had their surgery before October 28, 1980. We therefore agree with the Secretary that exhaustion is in no sense futile for these three respondents, and that the Court of Appeals erred in second-guessing the Secretary's judgment. [Footnote 11] Page 466 U. S. 619
Respondents also argue that there would be a presumption against them as they pursue their administrative appeals because of the very existence of the Secretary's instructions and her formal ruling and thus that exhaustion would not fully vindicate their claims. The history of this litigation as recited to us by respondents belies that conclusion. Indeed, according to respondents themselves, in every one of 170 claims filed with ALJs between the time of the Secretary's instructions to her intermediaries and the filing of this lawsuit, before the formal ruling became effective, ALJs allowed recovery for BCBR claims. Brief for Respondents 3. In promulgating the formal ruling, the Secretary took pains to exempt from the scope of the ruling individuals in respondents' position who may have had the surgery relying on the favorable ALJ rulings. 45 Fed.Reg. 71427 (1980). Although respondents would clearly prefer an immediate appeal to the District Court, rather than the often lengthy administrative review process, exhaustion of administrative remedies is in no sense futile for these respondents, and they, therefore, must adhere to the administrative procedure which Congress has established for adjudicating their Medicare claims. [Footnote 12] Page 466 U. S. 620
Again, regardless of any arguably procedural components, we see Ringer's claim as essentially one requesting the payment of benefits for BCBR surgery, a claim cognizable only under § 405(g). Our discussion of the unavailabilty of mandamus jurisdiction over the claims of the other three respondents is equally applicable to Ringer. As to § 1331 jurisdiction, as with the other three respondents, all aspects of Ringer's claim "aris[e] under" the Medicare Act in that the Medicare Act provides both the substance and the standing for Ringer's claim, Weinberger v. Salfi, 422 U.S. at 422 U. S. 760-761. Thus, consistent with our decision with respect to the other three respondents, we hold that §§ 1331 and 1361 are not Page 466 U. S. 621 available as jurisdictional bases for vindicating Ringer's claim.
If we allow claimants in Ringer's position to challenge in federal court the Secretary's determination, embodied in her rule, that BCBR surgery is not a covered service, we would be inviting them to bypass the exhaustion requirements of the Medicare Act by simply bringing declaratory judgment actions in federal court before they undergo the medical procedure in question. Ibid. Congress clearly foreclosed the possibility of obtaining such advisory opinions from the Secretary herself, requiring instead that a claim could be filed for her scrutiny only after the medical service for which payment is sought has been furnished. See 42 U.S.C. §§ 1395d(a), 1395f(a); 42 CFR §§ 405.1662-495.1667 (1983). Under the Page 466 U. S. 622 guise of interpreting the language of § 405(h), we refuse to undercut that choice by allowing federal judges to issue such advisory opinions. Thus it is not the case that Ringer has no "claim" cognizable under § 405(g); it is that he must pursue his claim under that section in the manner which Congress has provided. Because Ringer has not given the Secretary an opportunity to rule on a concrete claim for reimbursement, he has not satisfied the nonwaivable exhaustion requirement of § 405(g). The District Court, therefore, had no jurisdiction as to respondent Ringer.
The dissent suggests that Salfi is distinguishable on two grounds. First, it seems to suggest that Salfi is distinguishable because, after rejecting the claim that there was jurisdiction under § 1331, the Court in Salfiwent on to conclude that there was jurisdiction under § 405(g). Post at 466 U. S. 633-635. We fail to see how the Court's conclusion that the claimants in Salfi had satisfied all of the prerequisites to jurisdiction Page 466 U. S. 623 under § 405(g) has anything at all to do with the proper construction of § 405(h). If the dissent is suggesting that the meaning of § 405(h) somehow shifts depending on whether a court finds that the waivable and nonwaivable requirements of § 405(g) are met in any given case, that suggestion is simply untenable.
The crux of the dissent's position as to § 1331 jurisdiction then seems to be that Ringer's claims do not "arise under" the Medicare Act so as to be barred by § 405(h), because Ringer and his surgeon have not yet filed, and indeed cannot yet file, a concrete claim for reimbursement because Ringer has not yet had BCBR surgery. Thus, in the dissent's view, if a claimant wishes to claim entitlement to benefits in advance Page 466 U. S. 624 of undergoing the procedure for which payment is sought, his claim does not "arise under" the Medicare Act, and hence he is not precluded by § 405(h) from resorting to federal question jurisdiction. But that argument amounts to no more than an assertion that the substance of Ringer's claim somehow changes and "arises under" another statute simply because he has not satisfied the procedural prerequisites for jurisdiction which Congress has prescribed in § 405(g).
With respect to our holding that Ringer has not satisfied the nonwaivable requirement of § 405(g), the dissent adopts the remarkable view that the Secretary's promulgation of a Page 466 U. S. 625 rule regarding BCBR surgery satisfies that nonwaivable requirement. The dissent would thus open the doors of the federal courts in the first instance to everyone -- those who can and those who cannot afford to pay their surgeons without reliance on Medicare -- who thinks that he might be eligible to participate in the Medicare program, who thinks that someday he might wish to have some kind of surgery, and who thinks that this surgery might somehow be affected by a rule that the Secretary has promulgated. Of course, it is of no great moment to the dissent that, after adjudicating his claim in federal court, that individual may simply abandon his musings about having surgery. And it is of no great moment to the dissent that Congress, who surely could have provided a scheme whereby claimants could obtain declaratory judgments about their entitlement to benefits, has instead expressly set up a scheme that requires the presentation of a concrete claim to the Secretary.
The dissent's declaratory judgment notion effectively ignores the scheme which Congress has created, and does nothing less than change the whole character of the Medicare system. The dissent argues that its frustration of Congress' scheme can be limited to the situation where the Secretary has promulgated a rule, or, in the dissent's words, where she has "already issued an advisory opinion" about a certain surgical procedure in the form of a generally applicable rule. Post at 466 U. S. 642-643. Such a quest for restraint is admirable, but the logic of the dissent's position makes the quest futile. The dissent's concern in this case is with those perhaps millions of people, like Ringer, who desire some kind of controversial operation but who are unable to have it because their surgeons will not perform the surgery without knowing in advance whether they will be victorious in challenging the Secretary's rule in the administrative or later in the judicial process. Post at 466 U. S. 629-630, 466 U. S. 643. But that concern exists to the same degree with any claimant, even in the absence of a generally applicable ruling by the Secretary. For example, a Page 466 U. S. 626 surgeon called upon to perform any kind of surgery for a prospective claimant would, in the best of all possible worlds, wish to know in advance whether the surgery is "reasonable and necessary" within the meaning of the Medicare Act. And indeed some such surgeons may well decline to perform the requested surgery because of fear that the Secretary will not find the surgery "reasonable and necessary," and thus will refuse to reimburse them. The logic of the dissent's position leads to the conclusion that those individuals, as well as Ringer, are entitled to an advance declaration so as to ensure them the opportunity to have the surgery that they desire.
from the Secretary's conclusion that BCBR surgery is never "reasonable and necessary." Page 466 U. S. 627 Brief for Respondents 31. But respondents Holmes, Webster-Zieber, and Vescio are not subject to the Secretary's formal ruling, and stood the chance of prevailing in administrative appeals. Respondent Ringer has not undergone the procedure, and could prevail only if federal courts were free to give declaratory judgments to anyone covered by Medicare as to whether he would be entitled to reimbursement for a procedure if he decided later to undergo it.
The Medicare Act is designed to insure the elderly against the often crushing costs of medical care. [Footnote 2/1] To that end, § 1862(a)(1) of the Act guarantees payment of all expenses "reasonable and necessary for the diagnosis or treatment of Page 466 U. S. 628 illness or injury." [Footnote 2/2] The Secretary has issued a formal ruling stating that she will not pay the costs of bilateral carotid body resection (BCBR) surgery performed after October 28, 1980, in order to treat pulmonary distress because, for that purpose, BCBR is neither medically reasonable nor necessary. 45 Fed.Reg. 71426-71427 (1980). Respondents contend that the rule was not adopted in accord with the relevant limitations on the Secretary's authority.
The three respondents who have undergone the BCBR procedure all did so prior to October 28, 1980. The Secretary's ruling as of that date does not prevent them from obtaining payment for BCBR, and in fact states that they may prevail if they demonstrate that they underwent the procedure in reliance on previous rulings indicating that BCBR is reimbursable. [Footnote 2/3] I agree with the Court that the Secretary's ruling does not foreclose relief for them, and that it is therefore appropriate to require them to exhaust their administrative remedies. If, after the administrative process is complete, these respondents are dissatisfied with the Secretary's decision, they may obtain judicial review pursuant to § 205(g) of the Social Security Act. [Footnote 2/4] Page 466 U. S. 629
Today, the majority holds that Ringer must have the operation that he cannot afford and cannot obtain because of the Secretary's ruling before he can challenge that ruling. As I understand it, the Court concludes that there is no federal question jurisdiction over this case under 28 U.S.C. § 1331 [Footnote 2/7] Page 466 U. S. 630 because Ringer has a "claim arising under the Medicare Act," ante at 466 U. S. 621, which cannot be asserted under § 1331 by virtue of § 205(h) of the Social Security Act. [Footnote 2/8] Therefore, the Court continues, jurisdiction over this case can be exercised, if at all, under § 205(g). Yet the Court also holds that there is no jurisdiction under § 205(g), because Ringer has not submitted a claim for reimbursement. Of course, the reason he has not filed such a claim is that there is nothing to reimburse -- he has incurred no expenses, because he cannot afford to do so. Without anything to reimburse, the Secretary refuses to provide a hearing on what she and the Court believe to be a nonexistent "claim." Thus, the only way Ringer can pursue his § 205(g) remedy is by doing something that the Secretary will not let him do.
Thus, it would seem, Ringer both does and does not have a claim which arises under the Medicare Act. He cannot file a claim under the Medicare Act until after he has the operation; he cannot have the operation unless he can challenge the Secretary's ruling; and he cannot challenge that ruling except in an action seeking judicial review of the denial of a claim under the Medicare Act. This one-eyed procedural analysis frustrates the remedial intent of Congress as plainly as it frustrates this litigant's plea for a remedy. The cruel irony is that a statute designed to help the elderly in need of medical assistance is being construed to protect from administrative absolutism only those wealthy enough to be able to afford an operation and then seek reimbursement. Page 466 U. S. 631
Section 1869(a) of the Medicare Act provides that the determination whether an individual is entitled to Medicare benefits shall be made by the Secretary pursuant to prescribed regulations. [Footnote 2/10] Since the Secretary and the Court agree that Ringer has submitted no "claim" on which the Secretary Page 466 U. S. 632 could have acted, [Footnote 2/11] it is perfectly clear that the Secretary has made no determination pertaining to Ringer that is covered by § 1869(a). [Footnote 2/12] Section 1869(b)(1)(C) states that an individual "dissatisfied with any determination made under subsection (a)" is entitled to the kind of hearing authorized by § 205(b) of Title II of the Social Security Act, and to judicial review as prescribed in § 205(g) of that Title. [Footnote 2/13] Since there has been no "determination" in this case, this provision does not apply to Ringer either. [Footnote 2/14]
We come then to § 1872, which, in relevant part, provides that § 205(h) shall "apply with respect to this subchapter to the same extent as [it is] applicable with respect to subchapter II of this chapter." [Footnote 2/15] Nowhere in this reticulated Page 466 U. S. 633 statutory scheme is there any requirement that every "question" arising under the Medicare Act must be litigated in an action brought under § 205(g). Quite the contrary § 1872 applies § 205(h) to "this subchapter," i.e., to the provisions concerning reimbursement determinations contained in § 1869. Yet not one of the provisions in that section is relevant to Ringer. Ringer's claim is not the type of claim covered by "this subchapter," since the subchapter applies only to the type of hearing provided for in § 205(b). What Ringer seeks is not the type of hearing provided for in § 205(b), which would arise under "this subchapter," but instead an action under the right-of-review provisions of the Administrative Procedure Act (APA), 5 U.S.C. §§ 701-706. [Footnote 2/16] Hence, 28 U.S.C. § 1331 provides jurisdiction to entertain such a claim. See Califano v. Sanders, 430 U. S. 99 (1977).
This analysis is confirmed by Weinberger v. Salfi, 422 U. S. 749 (1975). In that case, on which the majority relies so heavily, the Court held that, when a claimant seeks payment of benefits under the Social Security Act, his claim "arises under" that Act within the meaning of § 205(h), and hence may not be brought pursuant to 28 U.S.C. § 1331. [Footnote 2/17] The obvious difference between this case and Salfi is that Salfi had a claim which could be raised under §§ 205(b) and (g); indeed the Court upheld the exercise of jurisdiction over that case under § 205(g). See 422 U.S. at 422 U. S. 763-767. Salfi Page 466 U. S. 634 therefore had a "claim" under the Social Security Act, and fell within the literal language of § 205(h) because he had filed an application for payment of benefits; review of the decision on such an application falls within the preclusive provisions of § 205(h):
In contrast to Salfi, Ringer has no "claim" within the meaning of the Social Security Act -- because he is unable to have the operation, he cannot file an application for reimbursement, and no "decision of the Secretary" has been made denying such a claim [Footnote 2/18] which could fall under § 205(h). Hence he Page 466 U. S. 635 does not fall within the preclusive language of § 205(h), which requires the existence of a "claim arising under the Social Security Act." Section 205(h) cannot operate in this context as it was intended -- "to route review through § 205(g)." Sanders, 430 U.S. at 430 U. S. 103, n. 3. It thus simply has no application. Because Ringer cannot afford the operation and obtain judicial review under the relevant provisions of the Medicare Act, he has no "claim" that "arises under" that Act, and is unable to generate one. [Footnote 2/19]
There is yet another fundamental reason why § 205(h) does not preclude Ringer's claim. Section 205(h) precludes only actions "to recover" on a claim arising under the Social Security Act. That language plainly refers to an action in which the claimant seeks payment of benefits. Indeed, as I observed Page 466 U. S. 636 above, Salfi stressed that the claimant in that case sought the payment of benefits. [Footnote 2/20] Today's majority finds § 205(h) applicable because Ringer "is clearly seeking to establish a right to future payments should he ultimately decide to proceed with BCBR surgery." Ante at 466 U. S. 621. If Ringer were seeking payment of benefits, this might well be a different case, but that is plainly not what he seeks. Ringer seeks a declaration that the Secretary's BCBR rule is invalid and an injunction against its operation. He alleges that it is the "irrefutable presumption" contained in the rule -- which denies administrative law judges discretion to decide in a hearing under § 205(b) whether BCBR is reimbursable -- that prevents him from having the operation. [Footnote 2/21] Ringer disavows any desire to obtain a judicial determination that benefits must be paid to him. Brief for Respondents 6-7. Thus, Ringer is not seeking "to recover." Instead he seeks an injunction against this "irrefutable presumption." Such an injunction would not result in the payment of benefits, but merely remove the hurdle to his having the operation, since, under those circumstances, his physician would have some hope of obtaining reimbursement through the administrative process. [Footnote 2/22]
"Unlike the plaintiff in [Salfi], whose action was the run-of-mine type clearly fitting the language 'to recover Page 466 U. S. 637 on any claim arising under' Title II, the plaintiff in this case . . . raises only a procedural challenge, the adjudication of which will not affect the substantive question of continued entitlement to [Medicare] benefits."
Unfortunately the majority's errors in this case are not limited to its construction of § 205(h). For even if we assume that § 205(h) is applicable to Ringer's case, and that he can obtain judicial review only through § 205(g), the majority's disposition would still be incorrect. Page 466 U. S. 638
Id. at 424 U. S. 330. It is similarly unrealistic to think that the Secretary would reconsider her BCBR regulation in the context of a single adjudicatory proceeding. Page 466 U. S. 639 The regulation was issued to prevent claimants from litigating the reimbursability of BCBR in an adjudicatory context. Thus, the relevant decision of the Secretary here could not be any decision made in the administrative process; rather, it is the decision to issue the BCBR regulation. That "decision of the Secretary" satisfies the nonwaivable portion of § 205(g). [Footnote 2/27]
422 U.S. at 422 U. S. 765-766. [Footnote 2/28] Here, just as in Salfi, "a hearing [would] be futile and wasteful." Id. at 422 U. S. 767. [Footnote 2/29] The Secretary has stipulated that, if Page 466 U. S. 640 Ringer had the operation and filed a claim for reimbursement, it would be denied under the BCBR regulation. App. 32. Since the Secretary
Moreover, even if a claim such as Ringer's should ordinarily be exhausted, the waivable element is satisfied when there is a "colorable claim" that the claimant will be injured if forced to exhaust in a way that cannot be remedied by later payment of benefits. Ante at 466 U. S. 617-618. Ringer clearly has such a claim. He suffers from serious pulmonary distress, and represents that, if he does not get BCBR, he faces a risk Page 466 U. S. 641 of continued deterioration in his health, and even death. [Footnote 2/31] Surely, the injury Ringer faces while awaiting judicial review -- which, on the majority's view, he in any event can never obtain, because of his inability to afford the operation -- constitutes a collateral injury not remedied even if Ringer somehow could exhaust his administrative "remedy."
Eldridge, 424 U.S. at 424 U. S. 331 (footnote omitted). Ringer should be permitted to challenge the BCBR rule which causes this injury without satisfying the waivable requirements of § 205(g). [Footnote 2/32] Page 466 U. S. 642
The Court's inability to find a jurisdictional basis for Ringer's challenge to the Secretary's formal ruling stems in part from a concern that the Secretary and the federal courts would otherwise be flooded by requests for advisory opinions by individuals contemplating various forms of medical treatment. There is no need to evaluate this purely hypothetical concern, because this case presents no question concerning Ringer's "right" to an advisory opinion or the Secretary's "duty" to provide one. We may assume that the Secretary is under no duty to volunteer an opinion on the reimbursability of a given procedure, and yet sustain Ringer's claim. The reason is simple -- the Secretary has already issued an advisory opinion on BCBR. That is exactly what her BCBR regulation is. The regulation was specifically designed to prevent this issue from arising in a concrete adjudicatory context. Indeed, her ruling is far more significant than mere advice; it is a formal pronouncement directing the bureaucracy under her command to reject all claims for reimbursement for BCBR surgery, despite the uniform course of decision by a variety of Administrative Law Judges, as well as the Secretary's Appeals Council, that such claims qualify for reimbursement. Thus, this is not a case concerning a "right" to an advisory opinion. Rather, this case poses the question whether, once the Secretary issues a rule which has the effect of denying a Medicare beneficiary surgery, that beneficiary may obtain judicial review as to the validity of the rule. [Footnote 2/33] I see no reason why that question should be answered Page 466 U. S. 643 negatively. Medicare beneficiaries can obtain judicial review of all of the Secretary's adjudicatory decisions that deny them benefits; I am certain that Congress did not intend to preclude judicial review of the Secretary's legislative decisions which have the same effect. [Footnote 2/34]
The majority has decided that it is proper to prevent a citizen from ever challenging a rule which denies him surgery he desperately needs. Ringer cannot afford the operation, and therefore his "claim" can never be "pursued" in a reimbursement proceeding. In making this decision, the Court ignores a basic proposition of administrative law. What Justice Harlan wrote for the Court in Abbott Laboratories v. Gardner, 387 U. S. 136 (1967), illustrates the point: Page 466 U. S. 644
5 U.S.C. § 702, so long as no statute precludes such relief or the action is not one committed by law to agency discretion, 5 U.S.C. § 701(a). The Administrative Procedure Act provides specifically not only for review of "[a]gency action made reviewable by statute," but also for review of "final agency action for which there is no other adequate remedy in a court," 5 U.S.C. § 704. The legislative material elucidating that seminal act manifests a congressional intention that it cover a broad spectrum of administrative actions, and this Court has echoed that theme by noting that the Administrative Procedure Act's "generous review provisions" must be given a "hospitable" interpretation. Again, in Rusk v. Cort, [369 U.S. 367, 369 U. S. 379-380 (1967)], the Court held that only upon a showing of "clear and convincing evidence" of a contrary legislative intent should the courts restrict access to judicial review.
As Justice Harlan indicated, Abbott is but one in a long line of cases holding that nothing less than clear and convincing Page 466 U. S. 645 evidence of legislative intent to preclude judicial review is required before a statute will be construed to preclude the citizen's right to seek judicial redress for violations of his rights. [Footnote 2/35] Salfi itself applied this presumption to the Social Security Act, and construed § 205(h) to preclude judicial review in that case only because review was available under § 205(g). 422 U.S. at 422 U. S. 762. In our system of government under law, administrative absolutism is not the rule, but only the narrow exception.
Leedom v. Kyne, Page 466 U. S. 646 358 U. S. 184, 358 U. S. 190 (1958) (citations omitted) (quoting Switchmen v. National Mediation Board, 320 U. S. 297, 320 U. S. 300 (1943))
Of course, the integrity of the administrative exhaustion mechanism created by Congress is vital, and the Act should not be construed in a way that would undermine that system. But all Ringer seeks to do is challenge a rule that prevents him from having the operation and then seeking reimbursement through the statutory review system. It is not Ringer who is bypassing the administrative review system, but the Page 466 U. S. 647 Secretary, whose BCBR rule prevents persons such as Ringer from seeking administrative review of a concrete claim for benefits. I can find no evidence, much less clear and convincing evidence, that Congress intended to prohibit judicial review in these circumstances.
"* * * *" "(C) the amount of benefits under part A (including a determination where such amount is determined to be zero)"
See National Assn. of Home Health Agencies v. Schweiker, 223 U.S.App.D.C. at 213-214, 690 F.2d at 936-937; Humana of South Carolina, Inc. v. Califano, 191 U.S.App.D.C. at 378-379, 590 F.2d at 1080-1081; Mid Atlantic Nephrology Center, Ltd. v. Califano, 433 F.Supp. at 31-32; Gainville v. Richardson, 319 F.Supp. at 18 (three-judge court). See also Griffin v. Richardson, 346 F.Supp. 1226, 1230 (Md.) (three-judge court), summarily aff'd, 409 U.S. 1069 (1972).
See n. 4, supra. Section 205(g) also contains a statute of limitations and a venue requirement.