---
kind: "section"
citation: "42 C.F.R. § 478.14"
title: "42"
number: "478.14"
heading: "Applicability."
url: "https://uscodex.org/cfr/42/478.14"
---

# §478.14. Applicability.

- (a) **Basic provision.** This subpart applies to reconsiderations and hearings of a QIO initial denial determination involving the following issues:
  - (1) **Reasonableness of services.**
  - (2) **Medical necessity of services.**
  - (3) Appropriateness of the inpatient setting in which services were furnished or are proposed to be furnished.
- (b) **Concurrent appeal.** A reconsideration or hearing provided under this subpart fulfills the requirements of any other review, hearing, or appeal under the Act to which a party may be entitled with respect to the same issues.
- (c) **Nonapplicability of rules to related determinations.**
  - (1) A QIO may not reconsider its decision whether to grant grace days.
  - (2) Limitation of liability determinations on excluded coverage of certain services are made under [section 1879](/cfr/42/1879.md) of the Act. Initial determinations under [section 1879](/cfr/42/1879.md) and further appeals are governed by the reconsideration and appeal procedures in [part 405](/cfr/42/part405.md), [subpart I](/cfr/42/subpartI.md) of this chapter for determinations under Medicare Part A and Part B. References in those subparts to initial and reconsidered determinations made by an intermediary, carrier or CMS should be read to mean initial and reconsidered determinations made by a QIO.

## Notes

### Amendments

[50 FR 15372, Apr. 17, 1985; 50 FR 41887, Oct. 16, 1985. Redesignated at 64 FR 66279, Nov. 24, 1999; 82 FR 5139, Jan. 17, 2017]

### Source

Source: 50 FR 15372, Apr. 17, 1985, unless otherwise noted. Redesignated at 64 FR 66279, Nov. 24, 1999.

### Authority

Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh).

### Amendments

[50 FR 15372, Apr. 17, 1985; 50 FR 41887, Oct. 16, 1985. Redesignated at 64 FR 66279, Nov. 24, 1999; 82 FR 5139, Jan. 17, 2017]