Heckler v. Ringer

Title XVIII of the Social Security Act (the Medicare act) provided that a Medicare enrollee may receive coverage for medical services that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Congress authorized the secretary of the Department of Health and Human Services (the department) to determine whether a medical service is reasonable and necessary. In 1979 the secretary issued instructions to the intermediaries contracted to make coverage decisions that bilateral carotid body resection (BCBR surgery) claims should categorically be denied because of evidence that the surgery was not reasonable and necessary. The secretary then promulgated a formal rule that BCBR surgeries were not reasonable and necessary. In response to the promulgation of the formal rule, a group of four Medicare claimants (plaintiffs) sued Secretary Heckler (defendant) in federal district court, arguing that the secretary’s refusal to provide coverage for the BCBR surgery violated due process and statutory law. Three of the Medicare claimants had already had the BCBR surgery. One of the claimants, Freeman Ringer, had not had the surgery because he knew the procedure would not be covered. The district court believed itself to lack jurisdiction over the claims because the Medicare act required claimants to exhaust all administrative remedies prior to seeking judicial review of their denied claims for the purpose of recovering benefits. Therefore, the district court dismissed the claim. The matter was appealed. The United States Court of Appeals for the Ninth Circuit reversed on the ground that exhaustion was not required because the claimants were seeking to invalidate a rule rather than seeking an entitlement to benefits. The matter was appealed to the United States Supreme Court.