In re LCD Complaint: 3D Interpretation and Reporting of Imaging Studies (L35408), DAB CR5234 (2019)

DECISION DISMISSING UNACCEPTABLE COMPLAINT

Daniel W. Adams, Jr. (the Aggrieved Party), submitted correspondence dated November 12, 2018, which the Civil Remedies Division treated as a challenge to a local coverage determination (LCD); docketed as styled above, C-19-184; 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 Aggrieved Party’s filing, I concluded that it was not 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, dated December 6, 2018, I informed the Aggrieved Party that he had one opportunity to submit an acceptable complaint.  See 42 C.F.R. § 426.410(c)(1).

My December 6 Order listed the information that is required to be included in an LCD complaint to make it acceptable.  I specifically directed the Aggrieved Party to provide all of the following information:

• Treating Physician Written Statement.  A copy of a written statement from the treating physician that the beneficiary needs the service that is the subject of the LCD.  This statement may be in the form of a written order for the service or other documentation from the beneficiary’s medical record (such as progress notes or discharge summary) indicating that the beneficiary needs the service.

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• LCD-identifying information.  The specific provision(s) of the LCD adversely affecting the aggrieved party.
• Aggrieved party statement.  A statement from the aggrieved party explaining what service is needed and why the aggrieved party thinks that the provision(s) of the LCD is (are) not valid under the reasonableness standard.
• Clinical or scientific evidence.  Copies of clinical or scientific evidence that support the complaint and an explanation for why the aggrieved party thinks that this evidence shows that the LCD is not reasonable.

My December 6 Order directed the Aggrieved Party to file the amended complaint by January 7, 2019.  I advised the Aggrieved Party that if he 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).

The Aggrieved Party failed to respond to my December 6 Order.  Therefore, for the reasons explained in that Order, the November 12, 2018 complaint submitted by the Aggrieved Party 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.