Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The following provides new guidance and clarifies previous guidance in FAQs about Families First Coronavirus Response Act and Coronavirus Aid, Relief, and Economic Security Act Implementation Part 43. The Families First Coronavirus Response Act (FFCRA) was enacted on March 18, 2020.1 Section 6001 of the FFCRA generally requires group health plans and health insurance issuers offering group or individual health insurance coverage, including grandfathered health plans, to provide benefits for certain items and services related to testing for the detection of SARS-CoV-2, which is the virus that causes COVID-19, or the diagnosis of COVID-19 when those items or services are furnished on or after March 18, 2020, and during the applicable emergency period.2 Under the FFCRA, plans and issuers must provide this coverage without imposing any cost-sharing requirements (including deductibles, copayments, and coinsurance), prior authorization, or other medical management requirements. The CARES Act was enacted on March 27, 2020.3 Section 3201 of the CARES Act amended section 6001 of the FFCRA to include a broader range of diagnostic items and services that plans and issuers must cover without any cost-sharing requirements, prior authorization, or other medical management requirements. Section 3202(a) of the CARES Act generally requires plans and issuers providing coverage for these items and services to reimburse any provider of COVID-19 diagnostic testing an amount that equals the negotiated rate or, if the plan or issuer does not have a negotiated rate with the provider, the cash price for such service that is listed by the provider on a public website. (The plan or issuer may negotiate a rate with the provider that is lower than the cash price.) Additionally, during the public health emergency related to COVID-19 declared under section 319 of the Public Health Service Act (PHS Act) (referred to in this document as the PHE for COVID-19), section 3202(b) of the CARES Act and implementing regulations at 45 CFR Part 182 require providers of diagnostic tests for COVID-19 to make public the cash price of a COVID-19 diagnostic test on the provider's public internet website or face potential enforcement action including civil monetary penalties. As stated in FAQs Part 43, Q3, any health care provider acting within the scope of their license or authorization can make an individualized clinical assessment regarding COVID-19 diagnostic testing.6 If an individual seeks and receives a COVID-19 diagnostic test from a licensed or authorized provider, including from a state- or locality-administered site, a "drive-through" site, and/or a site that does not require appointments, plans and issuers generally must assume that the receipt of the test reflects an "individualized clinical assessment." The FFCRA and the CARES Act make no distinction between point-of-care and other tests; all COVID-19 diagnostic tests that meet one of the criteria outlined in section 6001 of the FFCRA, as amended by section 3201 of the CARES Act, must be covered without cost sharing, prior authorization, or medical management (including for asymptomatic individuals with no known or suspected exposure to COVID-19). You can find this information at the Centers for Medicare and Medicaid Services, Internet Only Manual, Section 6001 of the FFCRA, as amended by section 3201 of the CARES Act; Sections 3202 and 3203 of the CARES Act; Sections 2713, 2715(d)(4), 2719, 2722, 2763, and 2791(c) of the Public Health Service Act; and 45 CFR 146.145(b)(3)(vi), 147.200(b), and 147.130.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.