995 F.3d 718
9th Cir.2021Background:
- Dr. Robert H. Odell, a Nevada physician treating Medicare patients, disputes how the regional Medicare contractor classifies and denies reimbursement for his nerve-block treatments.
- Contractor uses Local Coverage Determination (LCD) L28271; Odell contends his treatments fall under LCD L28240 and that the contractor applies an "unwritten rule" to deny his claims.
- Odell pursued multiple administrative appeals with mixed results (some ALJ rulings in his favor, some unfavorable decisions), but did not secure a final adverse Secretary decision for the claims at issue.
- Odell sued the Secretary seeking a broad injunction barring the contractor from applying L28271 to his claims without individual medical reviews; district court excused exhaustion as futile and granted a preliminary injunction.
- The Ninth Circuit held the district court lacked subject-matter jurisdiction because Odell had not satisfied §405(g)’s nonwaivable presentment requirement for any claim (including prospective claims), vacated the injunction, and remanded with instructions to dismiss for lack of jurisdiction.
Issues:
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Jurisdiction under §405(g)/presentment requirement | Odell has presented his claims via administrative appeals and may litigate agency-wide practice now | §405(g) permits judicial review only of "final decision[s]" after a claim is presented to the Secretary | Presentment is jurisdictional and nonwaivable; Odell failed to present any specific final adverse decision, so no jurisdiction |
| Excuse of exhaustion/futility | Exhaustion would be impractical/futile to appeal hundreds of claims piecemeal | Even if exhaustion is waivable, presentment is nonwaivable and cannot be excused | Even assuming futility excused exhaustion, presentment still bars jurisdiction |
| Prospective, programmatic injunctive relief against contractor practice | Court should enjoin contractor’s categorical application of L28271 to Odell’s future claims | Future claims not yet presented; administrative channels exist for each claim | No jurisdiction over future claims because they have not been presented to the agency |
| Applicability of Haven Hospice (alternative statutory route) | Haven Hospice permits facial challenges and supports district-court review here | Haven relied on a different statutory provision (§1395oo(f)(1)) and is distinguishable | Haven is inapposite; this case must proceed under §405(g) framework, which limits review |
Key Cases Cited
- Weinberger v. Salfi, 422 U.S. 749 (1975) (§405(g) authorizes review only of final, after‑hearing agency decisions; finality is central to jurisdiction)
- Mathews v. Eldridge, 424 U.S. 319 (1976) (presentment of a claim to the Secretary is a nonwaivable jurisdictional prerequisite)
- Shalala v. Illinois Council on Long Term Care, Inc., 529 U.S. 1 (2000) (even collateral constitutional challenges require claim presentment before judicial review)
- Heckler v. Ringer, 466 U.S. 602 (1984) (limits on district-court review where administrative remedies and presentment are the proper channels)
- Smith v. Berryhill, 139 S. Ct. 1765 (2019) (distinguishes two elements: jurisdictional presentment and waivable exhaustion)
- Porzecanski v. Azar, 943 F.3d 472 (D.C. Cir. 2019) (future claims cannot satisfy §405(g) presentment requirement because they have not arisen)
- Sensory NeuroStimulation, Inc. v. Azar, 977 F.3d 969 (9th Cir. 2020) (administrative channel existence forecloses alternative judicial routes)
- Haro v. Sebelius, 747 F.3d 1099 (9th Cir. 2014) (outlines Medicare administrative review steps required before judicial review)
- Pacific Coast Medical Enterprises v. Harris, 633 F.2d 123 (9th Cir. 1980) (even identical legal/factual issues require presentment for each claim)
- Los Angeles Haven Hospice, Inc. v. Sebelius, 638 F.3d 644 (9th Cir. 2011) (permitted a facial challenge under §1395oo(f)(1); distinguishable from §405(g) review)
- Kaiser v. Blue Cross of California, 347 F.3d 1107 (9th Cir. 2003) (challenges to Medicare program operation generally require an agency decision before judicial review)