CMS Pub. 100-04, ch. 34, § 10.11.2

Material Evidence

(Rev. 1671, Issued: 01-16-09; Effective/Implementation Date: 02-16-09)

In determining whether good cause exists for reopening an initial determination or

redetermination, the contractor considers whether evidence is new and material from the

perspective of the person or entity requesting or initiating the reopening.

When a party requests a reopening of an initial determination or redetermination for good

cause based on the submission of new and material evidence, the following policies

apply:

• The mere submission of additional evidence is not necessarily sufficient to

establish good cause to reopen an initial determination or decision. The information must

be “new,” (i.e., not readily available or known to exist at the time of the initial

determination) as well as material (i.e., may result in a different conclusion). A party

should explain how the information constitutes new and material evidence that

establishes good cause. If the contractor is unable to determine whether the information

submitted with a reopening request constitutes new and material evidence, the contractor

may decide not to grant the reopening.

• When a request for reopening is submitted with new and material evidence, but

additional information or evidence is needed before a proper revised determination or

decision can be made, the contractor may contact the party seeking the reopening, and

request that they obtain and submit the additional information. If the person or entity

requesting the reopening cannot obtain the additional information, the Medicare

contractor assists to the extent that it is reasonably able to do so.

When a Medicare contractor initiates a reopening of an initial determination or

redetermination for good cause based on the existence of new and material evidence, the

following policies apply:

• The contractor is responsible for clearly documenting in the case file the new and

material evidence that represents good cause for reopening.

• In order to promote administrative efficiency, Medicare does not generally require

that a party submit supporting medical documentation with the initial claim. Therefore, if

a medical record or other supporting documentation was not utilized when a contractor

made an initial determination, because it was not requested or was not provided, then the

content of any medical records or supporting documentation which are subsequently

requested by the contractor during the course of its review would constitute new

evidence.