Reversed Denials by Administrative Law Judges on Open Cases

4.8.1 – Reversed Denials by Administrative Law Judges on Open Cases (Rev. 11962; Issued: 04-21-23; Effective: 05-22-23; Implementation: 05-22-23) If a case is still pending at the OIG, FBI, or AUSA, and denials are reversed by an Administrative Law Judge (ALJ), the UPIC should recommend to CMS that it consider protesting the ALJ’s decision to the DHHS Appeals Council, which has the authority to remand or reverse the ALJ’s decision. UPICs should be aware, however, that ALJs are bound only by statutory and administrative law (federal regulations), CMS rulings, and National Coverage Determinations. The UPIC shall consult with its BFL, with a copy to the COR, before initiating a protest of an ALJ’s decision. They should be aware that the Appeals Council has only 60 days in which to decide whether to review an ALJ’s decisions. Thus, CMS needs to protest the ALJ decision within 30 days of the decision, to allow the Appeals Council to review within the 60-day limit. The UPIC shall notify all involved parties immediately if it learns that claims/claim denials have been reversed by an ALJ in a case pending prosecution.