## Facts

- Medicare Part A reimburses covered hospital-related services but excludes services not “reasonable and necessary” for diagnosis or treatment.
- Judicial review of Medicare Part A disputes is channeled through 42 U.S.C. § 405(g) (as incorporated), and § 405(h) makes that route exclusive for claims “arising under” the Medicare Act.
- In 1979, the Secretary of Health and Human Services directed Medicare intermediaries not to pay claims for bilateral carotid body resection (BCBR) performed to relieve respiratory distress.
- Before a later binding ruling, ALJs and the Appeals Council had often authorized payment for denied BCBR claims.
- On October 28, 1980, the Secretary issued a ruling prohibiting ALJs and the Appeals Council from ordering payment for BCBR operations occurring after that date on the ground that BCBR was not “reasonable and necessary.”
- Three claimants underwent BCBR before October 28, 1980 and filed Part A reimbursement claims that were denied at the intermediary level; Ringer did not undergo the surgery and had not filed a claim, asserting he could not afford the procedure without coverage assurance.
- The claimants sued in federal court without completing administrative review, seeking declaratory and injunctive relief requiring payment for BCBR and relieving them of further administrative appeals, invoking § 1331, mandamus (§ 1361), and § 405(g).
- The court of appeals allowed the suit to proceed in substantial part; the Supreme Court granted review.

## Issues

1. Whether the claimants’ challenges to the Secretary’s BCBR coverage policy are “claims arising under” the Medicare Act such that § 405(h) makes § 405(g) the exclusive route to judicial review.
2. Whether claimants may bypass § 405(g)’s “final decision” and exhaustion requirements by pleading federal-question jurisdiction under § 1331 or seeking mandamus under § 1361.
3. Whether exhaustion should be waived on the theory that the requested relief is prospective or collateral to individual benefits determinations.

## Decision

- The Supreme Court reversed the court of appeals (6–3).
- The Court held the claims “arise under” the Medicare Act because the Act supplies the substantive basis for the claims and the requested relief is, in practical effect, payment of Medicare benefits and invalidation of a coverage policy governing those benefits.
- Section 405(h) bars § 1331 jurisdiction for such claims and channels them exclusively through § 405(g) review.
- Because the claimants had not obtained a “final decision” after completing the prescribed administrative process, federal courts lacked jurisdiction; Ringer also lacked any benefits determination because he had not filed a claim.
- Mandamus could not supply jurisdiction because the Secretary owed no clear, nondiscretionary duty to authorize payment for BCBR; the “reasonable and necessary” determination involves agency judgment.

## Legal Principles

- A claim “arising under” the Medicare Act must be presented and channeled through the administrative process culminating in judicial review under 42 U.S.C. § 405(g); § 405(h) makes this route exclusive and precludes § 1331 jurisdiction.
- A claim arises under the Act where the Act provides the standing and substantive basis for relief, or where the challenge is inextricably intertwined with a claim for benefits.
- The Secretary may define, by regulation, what constitutes a “final decision” for § 405(g) review, including requiring exhaustion of designated administrative steps.
- Courts will not waive exhaustion merely because the plaintiff frames the dispute as a policy attack or requests declaratory or injunctive relief when the practical objective is payment of benefits.
- Mandamus requires a clear, ministerial, nondiscretionary duty; it is unavailable to compel discretionary coverage determinations.

## Conclusion

The Court required Medicare claimants challenging a coverage policy tied to benefits to proceed through the statutory administrative review scheme and obtain a final agency decision before seeking judicial review, rejecting attempts to bypass that channeling requirement through § 1331 or mandamus.


Heckler v. Ringer, 466 U.S. 602 (1984)