Mansfield Ambulance, Inc. v. Department of Health and Human Services et al
Memorandum of Opinion and Order: Plaintiff's Motion for Summary Judgment is DENIED and Defendants' Cross Motion for Summary Judgment is GRANTED.Judge Patricia A. Gaughan on 5/10/17. (LC,S) re 19 , 20
UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF OHIO
Mansfield Ambulance, Inc.,
Dep’t Health and Human Services, et. al., )
CASE NO. 1:16 CV 2016
JUDGE PATRICIA A. GAUGHAN
Memorandum of Opinion and Order
This matter is before the Court upon Plaintiff’s Motion for Summary Judgment (Doc. 19)
and Defendants’ Cross Motion for Summary Judgment (Doc. 20). This is an action for judicial
review of the final decision of the Secretary of Health and Human Services concluding that
plaintiff owes an overpayment in connection with the Medicare program. For the reasons that
follow, plaintiff’s motion is DENIED and defendants’ motion is GRANTED.
The facts of this case are taken from the Administrative Record (“AR”) filed in this case.
Plaintiff is a provider of ambulatory services to patient beneficiaries and seeks
reimbursement for those services under Medicare Part B. The parties do not dispute that under
Medicare Part B, defendant1 has the authority to enter into contracts with private entities to
perform administrative functions including ascertaining whether certain services are “medically
necessary.” In this case, Palmetto GBA (“Palmetto”) performed this service on behalf of
defendant with respect to plaintiff.
With respect to ambulatory services, Medicare requires that the ambulatory service be
“medically necessary” in order for the claim to be paid. This can be established upon a showing
that the patient’s condition is such that the use of any other method of transportation is
contraindicated. Medicare also covers “nonemergency, scheduled, repetitive ambulance
services” in certain circumstances. Plaintiff provided a physician’s certification (“PC”) in
support of its position that some of its claims should be covered. In addition, with respect to
certain ambulatory services, plaintiff obtained “pre approval” from Palmetto. Plaintiff received
payment from the Medicare Trust for ambulatory services it provided to patients.
Defendant has the authority to enter into contracts with entities to perform reviews and
audits. According to defendant, these entities were formerly known as Program Safeguard
Contractors and are now known as Zone Program Integrity Contractors. AdvancedMed is one
such entity. In 2010, Palmetto requested that AdvanceMed audit plaintiff’s claims for payment.
AdvanceMed initially conducted a “probe” of 59 claims (representing 116 services) for 10
Plaintiff brings this action against both the Department of Health
and Human Services and the Secretary of the Department of
Health and Human Services. For ease of reference, the Court will
refer to these defendants in the singular.
patients. AdvanceMed obtained medical records from plaintiff, as well as nursing homes,
hospitals, and dialysis centers. Of these 116 services, 83 claims were allowed as billed, 30
claims were denied because the documentation did not support the need for ambulance transfer,
and three services were allowed but “downcoded.” As a result of the probe, AdvanceMed
expanded the review to a Statistical Sampling for Overpayment Estimation (“SSOE”). The
SSOE included a review of 242 services. Of those services, AdvanceMed allowed 78 of the
claims and denied 162 claims. The remaining two claims were reduced for mileage as the
patient was not taken to the nearest facility. (AR at 443-448). The claims are reviewed by a
physician based on the documentation submitted. In some instances, the claims were found to be
improper even though a PC was submitted for the patient.
Based on the SSOE, AdvanceMed calculated the payment error rate to be 56.88%. (AR
at 211). AdvanceMed then extrapolated an overpayment based on the remaining universe of
claims submitted by plaintiff. The statistical sampling and extrapolation resulted in an
overpayment by defendant of $361,940.00 based on the SSOE and $2,978.86 based on the probe,
for a total overpayment of $364,918.86. (AR 443).
Subsequently, it appears that Palmetto was replaced by an entity known as CGS.
Plaintiff requested a redetermination by CGS of the assessed overpayment. CGS confirmed that
none of the claims were covered and affirmed AdvanceMed’s findings in whole. The total
amount of the repayment was reduced slightly due to a fee schedule discrepancy. Accordingly,
CGS determined that the total amount of repayment to be made by plaintiff equaled $364,874.86.
CGS also rejected any argument that plaintiff was entitled to a waiver of repayment. CGS
concluded that provider manuals, medicare bulletins, and various other materials serve as notice
of Medicare’s requirements. As such, it cannot be said that plaintiff was “without fault” in
causing the overpayment.
After the redetermination by CGS, plaintiff sought review by a qualified independent
contractor (“QIC”). In this case, C2C Solutions (“C2C”) acted as the QIC. During this review,
C2C reviewed 167 claims and found in plaintiff’s favor with respect to 34 claims, and partially
in plaintiff’s favor as to an additional claim. With respect to the remaining 132 claims, C2C
made an unfavorable determination and upheld the overpayment.
In response to the QIC review, plaintiff sought a hearing before an administrative law
judge (“ALJ”). Two statisticians testified at the hearing. Ultimately, the ALJ issued a partially
favorable decision with respect to only two claims. With regard to the majority of the
ambulatory services, the ALJ concluded that the records did not show that the transports were
medically necessary. The ALJ further concluded that the statistical sample and subsequent
extrapolation were valid and that plaintiff was not “without fault” in causing the overpayment.
Ultimately, the ALJ ordered:
The random sample and statistical extrapolation performed by the PSC/ZPIC in this case
are valid, and the Appellant is liable to refund the overpayment it received. In order to
determine the amount of the remaining overpayment, the appropriate Medicare contractor
must execute a new, statistically valid extrapolation based on this partially favorable
decision, and thereafter issue a notice of revised overpayment amount.
Plaintiff then appealed the ALJ’s decision to the Medicare Appeals Council (“Council”).
The council upheld the ALJ’s determinations, with the slight exception regarding interest, which
is not relevant to this appeal.
Plaintiff appealed the Council’s decision to this Court and the parties now cross-move for
summary judgment. Each opposes the other’s motion.
Use of extrapolation
Plaintiff argues that defendant erred in using extrapolation to determine the amount of
overpayment. The statutory framework governing Medicare expressly addresses the use of
3) Limitation on use of extrapolation
A medicare contractor may not use extrapolation to determine overpayment amounts to
be recovered by recoupment, offset, or otherwise unless the Secretary determines that–
(A) there is a sustained or high level of payment error; or
(B) documented educational intervention has failed to correct the payment error.
There shall be no administrative or judicial review under section 1395ff of this title,
section 1395oo of this title, or otherwise, of determinations by the Secretary of sustained
or high levels of payment errors under this paragraph.
42 U.S.C. § 1395ddd(f)(3).
Here, the initial payment error rate equaled 56.88%. Plaintiff points to no statute or
regulatory provision requiring defendant to expressly note that an error rate of nearly 60%
qualifies as a “high error rate.” It is implicit in defendant’s use of extrapolation to calculate the
repayment that defendant determined the rate to be “high.” See, Minet v. Sebelius, 2012 WL
2930746 (finding that an error rate of 100% with no express finding is implicitly a “high level of
payment error.”). And, as noted by defendant and expressly set forth in the statute, this Court
cannot review defendant’s determination of a “high level of payment error.” See, e.g., Gentiva
Healtcare Corp. v. Sebelius, 723 F.3d 292, 296 (D.C. Cir. 2013)(“We also agree with the district
court that § 1395ddd(f)(3) precludes us from reviewing the merits of the “sustained or high level
of payment error” determination that permitted the contractor to use extrapolation to calculate
overpayment amounts in this case.”). This preclusion of judicial review applies even when the
administrative appeals process reduces the total overpayment due and defendant orders reextrapolation. See, e.g., Momentum EMS, Inc. v. Sebleius, 2014 WL 199061 at *2 (S.D. Tex.
Jan. 13, 2014); John Balko & Associates, Inc. v. Sebelius, 2012 WL 6738246 (W.D. Pa. Dec. 28,
2012)(“whether that determination was made at the appropriate time is immaterial to this Court's
jurisdiction to adjudicate...[the] high error rate argument. The language of the statute is
unambiguous, that there “shall be no ... judicial review ... of determinations by the Secretary of
sustained or high levels of payment errors under this paragraph.”); Morgan v. Sebelius, 2012 WL
1231960 (S.D.W.Va. April 12, 2012)(“The central thrust of this argument is that his repayment
amount has been so drastically reduced during the course of Dr. Morgan's appeals, from
$614,222.95 to $61,922, that the reduced amount cannot justify a finding of a sustained or high
level of payment error. While this is intuitively appealing, Plaintiff's argument ultimately fails
[because such determinations are non-reviewable.]”). See also, 42 C.F.R § 405.926(p). Based
on the clear and unequivocal statutory language, this Court cannot review defendant’s
determination of a high level of payment error, including the timing of such determination.
Thus, plaintiff’s argument that defendant erred in not “re-determining” whether a high level of
payment error exists is unreviewable and the argument is rejected.
Plaintiff also argues that the use of extrapolation to determine the amount of overpayment
violates due process. Plaintiff claims that because defendant extrapolated the repayment instead
of addressing each claim individually, plaintiff cannot determine which patients to seek payment
from. According to plaintiff, this violates procedural due process. As defendant notes, circuit
courts generally recognize that the use of statistical sampling does not violate due process
provided the claimant has an opportunity to rebut the evidence. See, Chaves County Home
Health Services v. Sullivan, 931 F.2d 914 (D.C. Cir. 1991)(“the private interest at stake is easily
outweighed by the government interest in minimizing administrative burdens; in light of the
fairly low risk of error so long as the extrapolation is made from a representative sample and is
statistically significant, the government interest predominates”); Yorktown Medical Lab., Inc. v.
Perales, 948 F.2d 84 (2d Cir.1991)(no due process claim for use of extrapolation because
balancing of interests weighs in favor of the government); Ratanasen v. State of California,
Dep’t of Health and Human Servs., 11 F.3d 1467 (9th Cir. 1993)(“We now join other circuits in
approving the use of sampling and extrapolation as part of audits in connection with Medicare
and other similar programs, provided the aggrieved party has an opportunity to rebut such
evidence.”). The Sixth Circuit has also approved of the use of statistical sampling in connection
with the recovery of public funds. See, e.g., Michigan Dept. of Educ. v. U.S. Dept. of Educ., 875
F.2d 1196 (6th Cir. 1989).
Here, the Court rejects plaintiff’s claim that statistical sampling violates due process
because plaintiff will be unable to recover the repayment directly from the patient. During the
administrative process, defendant determined as follows:
We have reviewed the charges at issue with regard to whether the services were
reasonable and necessary. We found that the services were not reasonable and necessary.
We have further determined that the patients did not know and could not have been
expected to know that these services were not covered or not fully covered by Medicare.
However, we find that based upon the regulations cited above, you knew or could have
been expected to know, that these services were not covered or not fully covered by
Medicare. We also find that you did not notify the beneficiaries in writing, before the
services were furnished, that Medicare likely would not pay or not fully pay for the
Thus, defendant expressly determined that the services were not reasonable and
necessary and that the patients “did not know and could not have been expected to know” that
the services were not covered. Nonetheless, plaintiff argues that it can collect from these
patients because it was not required to provide the patients with an Advance Beneficiary Notice
(“ABN”), which would have alerted the patients that the service may not be covered by
Medicare. Plaintiff claims that an ABN is required before payment can be collected, but that
ambulance services are excluded from the requirement. The materials provided by plaintiff,
however, do not support this position. The Medicare publication MM7821, which plaintiff
attaches to his opposition brief, indicates that in certain circumstances an ABN cannot be issued.
Those services include emergency ambulance transportation. However, the publication
indicates that an ABN “must be issued” if the following three questions are answered in the
(1) Is this service a covered benefit?
(2) Will payment for part or all of this service be denied because it is not reasonable and
(3) Is the patient stable and the transport non-emergent?
Here, plaintiff does not dispute that Medicare covers “nonemergency, scheduled,
repetitive ambulance services,” but as set forth above defendant denied these services as “not
reasonable and necessary.” Nor does plaintiff argue that the transports involved an emergency.
As such, the Court is not convinced that plaintiff’s due process rights were violated by
extrapolation because plaintiff could have collected directly from the patients. The argument is
Next plaintiff claims that its due process rights were violated because of an
“unidentifiable discrepancy” in the claims reviewed by AdvanceMed and C2C. Plaintiff’s
argument is somewhat lacking in clarity, but it appears to be two-pronged. In his motion,
plaintiff’s argument in its entirety consists of the following:
There is an unidentified discrepancy in the number of claims reviewed by [AdvanceMed]
and [C2C]. [AdvanceMed] reviewed 59 claims. However, [C2C] reviewed 84.
The addition of claims previously not at issue makes it impossible for plaintiff to know
the claims at issue or to respond. This invalidates the sampling and makes extrapolation
improper. This error was brought to the attention of the [Council] but was not resolved.
This discrepancy makes the statistical sampling and extrapolation uncertain. The
extrapolation damages cannot be sustained, and constitutes a violation of due process of
Thus, it appears that plaintiff is claiming that due process is violated because plaintiff
does not know the precise claims at issue and, therefore, cannot respond in a meaningful way.
Plaintiff further argues that the addition of the claims invalidates the sampling. With regard to
plaintiff’s argument that it was unaware of what claims were at issue or how to respond thereto,
the argument is rejected. As defendant notes, both AdvanceMed and C2C provided spreadsheets
specifically identifying the claims at issue. Moreover, the spreadsheets created by C2C and the
ALJ provided specific reasons for the claim denials. It appears, however, from plaintiff’s brief
in opposition, that plaintiff no longer claims that it is unable to respond to the unidentified
claims. Rather, plaintiff’s focus is on the fact that the “probe” claims were added to the SSOE
claims, rendering the sampling invalid. As an initial matter, plaintiff did not fully develop this
argument in its own motion. Rather, plaintiff significantly expanded on this argument only in
opposition to defendant’s motion. Regardless, the Court finds that the argument lacks merit.
As noted by the ALJ, the use of statistical sampling does not offend due process. Rather,
it creates a presumption of validity as to the amount of overpayment (AR 115); HCFA Ruling
86-1.2 “The burden then shifts to the provider to take the next step.” Id. Here, the ALJ relied on
two statisticians in concluding that the sampling methodology on which extrapolation is based is
statistically sound. Plaintiff offers only generalized attorney argument suggesting that the
inclusion of claims involved in the probe somehow renders the sampling invalid. It appears that
plaintiff also presented this argument in unsupported fashion to the Council. (AR 9)(“The
appellant asserts, without further explanation, that there is an ‘unexplained difference in the
number of claims determined by [AdvanceMed] and [C2C]’ thereby invalidating the sampling
and resulting extrapolation.”). This is not sufficient to support a finding that the procedures
afforded to plaintiff to dispute the use of extrapolation violate due process. Nor is it sufficient to
warrant a finding that defendant’s determination in this regard is not supported by substantial
The Court further finds that the inclusion of pre-approved claims in the sampling does
not violate due process or render the statistical sampling invalid. Certain claims included in the
random sampling analysis were “pre-approved” before plaintiff provided the ambulatory service.
Plaintiff summarily argues that the inclusion of these claims renders the sample invalid. As one
statistician testified, however, the sample was in fact random because it selected from the entire
universe of post-paid claims. (AR 7547-49). It appears that to except a subset of those claims
would in fact render the sample non-random. Accordingly, the use of extrapolation does not
violate due process.3
In the opinion, the ALJ referred to this ruling as CMS Ruling 86-1.
It appears that the ruling is now known as HCFA Ruling 86-1.
In its brief in opposition, plaintiff argues that C2C improperly
disapproved a claim that plaintiff did not appeal and for which
Plaintiff argues that it complied with the Medicare requirements by obtaining PCs prior
to providing non-emergency transport services. In essence, plaintiff argues that the presence of a
PC for a patient automatically satisfies Medicare’s “medical necessity” requirement. In other
words, defendant improperly “overruled” the PC. In response, defendant argues that medical
necessity is always required for Medicare reimbursement. According to defendant, the
requirement that a PC be obtained for non-emergency transport services does not supplant the
rule. Rather, it adds a requirement for coverage to occur.
42 C.F.R. § 410.40 provides as follows:
(d)(2) Special rule for nonemergency, scheduled, repetitive ambulance services.
Medicare covers medically necessary nonemergency, scheduled, repetitive ambulance
services if the ambulance provider or supplier, before furnishing the service to the
beneficiary, obtains a written order from the beneficiary’s attending physician certifying
that the medical necessity requirements of paragraph (d)(1) of this section are met....
(d)(3) Special rule for nonemergency ambulance services that are either unscheduled or
that are scheduled on a nonrepetitive basis. Medicare covers medically necessary
nonemergency ambulance services that are either unscheduled or that are scheduled on a
nonrepetitive basis under of the following circumstances:
In all cases, the provider or supplier must keep appropriate documentation
of file and, upon request, present it to the contractor. The presence of the
signed certification statement or signed return receipt does not alone
demonstrate that the ambulance transport was medically necessary. All
other program criteria must be met in order for payment to be made.
At the time of the provision of the services at issue in this case, subsection (v) applied
approval had been provided by AdvanceMed. Plaintiff claims that
C2C lacked jurisdiction to review that claim. Plaintiff, however,
cites no law or regulation in support of its position.
only to “unscheduled” nonemergency ambulatory services. Subsequently, 42 C.F.R. § 410.40
was amended such that the paragraph became applicable to “scheduled” nonemergency
ambulatory services as well.
With regard to the existence of a PC, the Medicare Benefits Policy Manual provides as
Medical necessity is established when the patient's condition is such that use of any other
method of transportation is contraindicated. In any case in which some means of
transportation other than an ambulance could be used without endangering the
individual's health, whether or not such other transportation is actually available, no
payment may be made for ambulance services. In all cases, the appropriate
documentation must be kept on file and, upon request, presented to the A/B MAC (A) or
(B). It is important to note that the presence (or absence) of a physician’s order for a
transport by ambulance does not necessarily prove (or disprove) whether the transport
was medically necessary. The ambulance service must meet all program coverage criteria
in order for payment to be made.
(MBPM § 10.2.1)
Upon review, the Court rejects plaintiff’s argument. Plaintiff claims that the statutory
scheme clearly and unambiguously provides that the existence of a PC conclusively establishes
medical necessity. The provision relied on by plaintiff, however, provides that “Medicare covers
medically necessary nonemergency, scheduled, repetitive ambulance services if the ambulance
provider or supplier, before furnishing the service to the beneficiary, obtains a [PC].... 40 CFR §
410.40(d)(2)(emphasis added). This provision expressly requires that the service be “medically
necessary” before payment will be made, which is consistent with Medicare’s entire scheme.
The provision, however, places a further condition on providers of nonemergency scheduled
transport services. For these services, providers must also provide a PC. To accept plaintiff’s
interpretation of the provision would read the “medically necessary” entirely out of the statute
and make the language superfluous. The fact that subsection (v) initially appeared only with
respect to “scheduled” transport services does not alter the Court’s conclusion. At the very best,
this language’s absence from the subsection dealing with “scheduled” transports, renders the
provision ambiguous. But the Court will defer to the agency’s reasonable interpretation of its
regulation. Here, the agency’s reasonable interpretation as set forth in MBPM § 10.2.1 provides
that the existence of a PC does not automatically satisfy the “medical necessity” requirement.
The Court will defer to that interpretation.
Moreover, the Fifth Circuit expressly held that “possession of a [PC]–even one that is
legitimately obtained–does not permit a provider to seek reimbursement for ambulance runs that
are obviously not medically necessary.” See, United States v. Read, 710 F.3d 219 (5th Cir.
2012). Plaintiff attempts to distinguish Read on the basis that the case involved fraud on the part
of the provider in securing the PC. In fact, plaintiff concedes that in situations involving fraud,
the regulation cannot be read as plaintiff suggests. But, Read cannot be read so narrowly as the
court expressly noted that PCs–even those that are legitimately obtained–do not automatically
satisfy the medical necessity requirement. Moreover, plaintiff wholly fails to explain why
actions involving fraud– as opposed to gross negligence or the like– would be exempted from the
regulation. Regardless, the Court finds that the analysis in Read is persuasive and consistent
with this Court’s reasoning.4
Plaintiff relies on two unreported cases wherein district courts
have held that defendant erred in reviewing logs of ambulance runs
where PCs were on file. See, First Call Ambulance Service, Inc. V.
Dep’t Health and Human Servs., 2012 WL 769617 (MD. Tenn.
March 8, 2012); Moorecare Ambulance Service, LLC, Dep’t of
Health of Human Servs., 2011 WL 839502 (MD. Tenn. March 4,
2011). This Court disagrees with the reasoning contained in those
cases and declines to follow the rationales. The Court does not
read the statute as unambiguously preventing defendant from
3. “Without fault”
Plaintiff argues that defendant erred in permitting the review of claims for which precertification had been obtained. According to defendant, these claims should not be
reconsidered or reopened. Again, as with other issues raised in the briefing, plaintiff points to no
law or regulation that prohibits an audit from including claims for which providers obtained preapproval. As such, the argument is not well-taken.
Plaintiff’s argument that defendant erred in denying a limitation on liability for
overpayment is also rejected. As an initial matter, plaintiff relies on wholly inapplicable
provisions of the Code of Federal Regulations. The ALJ relied on 42 C.F.R. § 405.350(c) as
“guidance” for whether plaintiff is entitled to a “waiver” of the overpayment. In essence, the
ALJ concluded that in order to be exempt from repayment, plaintiff must have: (1) made full
disclosure of all material facts; and (2) on the basis of the available information, including
Medicare instructions and regulations, it had a reasonable basis for assuming the payment was
correct. The ALJ further cited Section 90.1 H of the Medicare Financial Management Manual
for the proposition that a “provider would be liable for refunding the overpayment if [it] billed
for items or services which it should have known were not covered; for instance, when the policy
or rule is in the provider manual or in the CFR.” (AR 116). Here, the ALJ concluded that
plaintiff is presumed to be aware of the widely publicized and strict requirements regarding
ambulance transport coverage. And, plaintiff is required to maintain and submit sufficient
medical documentation to justify that the transport qualifies as a covered claim. The ALJ
rejected plaintiff’s argument that the pre-certification somehow mandates a finding of “waiver,”
challenging the validity of a PC.
on the basis that the “transport records so obviously show that most Beneficiaries were able to sit
in a wheelchair, were therefore not bed-confined, and did not require medical monitoring en
route.” In other words, plaintiff’s own transport records demonstrate that the claims–even those
for which pre-certification was obtained – are not subject to Medicare coverage. Plaintiff does
not dispute any of the findings made by the ALJ.5 Accordingly, the Court finds that the ALJ’s
determination that plaintiff is required to make the repayment is supported by substantial
4. “Medical necessity”
Plaintiff makes a summary and undeveloped argument regarding “medical necessity.”
According to plaintiff’s motion, CMS has published ambulance codes that “make clear” that
there are four categories of patients that “may” be covered and that medical necessity is not
limited to patients who are “bed-confined.” Plaintiff then identifies these four codes. Plaintiff
points to four patients that plaintiff claims “clearly meet these criteria.” With respect to each
patient, plaintiff provides a basic description of the patient’s condition. By way of example,
plaintiff cites to patient V.B.:
V.B. Medical records show patient has left below-the knee amputation. Patient was
transferred by draw sheet when moved. Patient also has a right forefoot amputation and
Patient had an approved medical necessity Ambulance Coverage Pre Payment Claim
Decision for an indefinite period of time from Palmetto GBA.
Plaintiff, however, wholly fails to point to any regulation (or specific ambulance code for
Moreover, as defendant notes, the pre-certifications often spanned
a period of time, as opposed to specific ambulance transports.
Thus, the fact that certain trips were covered by a prior
certification diminishes plaintiff’s argument in that the precertification was not done on a claim by claim basis.
that matter) demonstrating that the ALJ’s decision to deny this claim is not supported by
substantial evidence. In response, defendant notes that ambulance codes themselves provide that
use of a code does not guarantee coverage. In its brief in opposition, plaintiff responds that it
“stands” on the motion with respect to the four patients, as the government offered no response.
But, the government responded with argument regarding why ambulance codes are not sufficient
to warrant coverage. This response is not unreasonable in light of the convoluted nature of the
issue as presented by plaintiff. Plaintiff developed no argument with respect to each of the four
patients and instead cites generically to facts regarding each of them. Plaintiff’s citation to
certain facts, standing alone, is not sufficient to warrant reversal of the ALJ’s decision with
respect to these four patients.
The Court further rejects plaintiff’s argument that the ALJ somehow required more
documentation than is required by CMS or, alternatively, the ALJ’s documentation requirements
are unconstitutionally vague. Again, this argument is only summarily developed. Regardless,
the ALJ made clear that while the documentation provided was sufficient to document medical
conditions, it “sorely lacks clinical evidence showing that the Beneficiaries were either confined
to a bed or that other methods of transportation were...contraindicated.” In other words, the ALJ
held that the documentation provided by plaintiff did not establish entitlement to payment by
Medicare for these ambulatory services. Plaintiff’s argument that the ALJ somehow required
“too much” documentation is rejected.
Plaintiff argues that a publication interpreting the Medicare Claims Processing Manual
directs that C2C was required to provide detailed explanations for its denials and that C2C failed
in this regard. In response, the government notes that AdvanceMed and the ALJ provided
detailed reasoning to support the denials. Plaintiff replies summarily that “plaintiff has been
deprived of its right to the process that is due....[T]his violation of Plaintiff’s Constitutional right
to due process should cause this case to be reversed.” The Court rejects plaintiff’s argument that
any failure by C2C to provide sufficiently detailed reasons for its denials somehow violates
plaintiff’s due process rights. Generally, these requirements are in place to permit judicial
review of plaintiff’s claims. Plaintiff does not argue or point to any instance in which any failure
on the part of C2C precludes adequate judicial review. This is especially so in that plaintiff does
not dispute that both AdvanceMed and the ALJ provided sufficient reasoning for the denials.
For this reason, plaintiff’s argument is rejected.
For the foregoing reasons, Plaintiff’s Motion for Summary Judgment is DENIED and
Defendants’ Cross Motion for Summary Judgment is GRANTED.
IT IS SO ORDERED.
/s/ Patricia A. Gaughan
PATRICIA A. GAUGHAN
United States District Judge
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