Amanda Brooke Halstrom, MD, DAB CR6867 (2026)

DECISION

Petitioner, Amanda Brooke Halstrom, MD, is a licensed physician, who opted out of the Medicare program.  Petitioner now seeks to end her opt-out status.  However, because Petitioner missed the deadline for canceling her opt-out status, the Centers for Medicare & Medicaid Services (CMS) denied her request.  Petitioner appeals that determination.

Because Petitioner missed the regulatory deadline, CMS properly denied Petitioner's request to cancel her Medicare opt-out status.  42 C.F.R. § 405.445(a).

Background

In an affidavit, dated May 18, 2023, and submitted to the Medicare administrative contractor, National Government Services, Inc. (NGS), Petitioner opted out of the Medicare program.  CMS Ex. 1.  Among other assurances, Petitioner agreed that, during the opt-out period, she would not submit a claim to Medicare for any service furnished to a Medicare beneficiary.  Id. at 2 ¶ 3.  Moreover, Petitioner recognized that the opt-out was for a period of two years and would automatically renew unless cancelled.  Id. at 2 ¶ 1.  Lastly, Petitioner acknowledged that, to cancel the automatic extension, she had to

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notify the Medicare contractor in writing at least 30 days prior to the start of the next opt-out period.  Id.

By letter dated July 17, 2023, NGS informed Petitioner that the effective date of her opt-out status was May 18, 2023.  CMS Ex 4.  NGS also informed Petitioner that the opt-out status was effective for two years and would automatically renew at the end of the initial two-year period.  Id. at 1.  NGS reminded Petitioner that in the event Petitioner wanted to cancel her opt-out status, she had to notify NGS of the cancellation in writing at least 30 days prior to the start of the next two-year opt-out period.  Id.

On May 22, 2024, Petitioner submitted a letter to NGS seeking an early termination of her Medicare opt-out status due to changes in her personal circumstances.  See CMS Ex. 2 at 24.  This request was returned because it was received more than 90 days prior to the end of Petitioner's opt-out period.  CMS Ex. 5 at 3.

In a letter dated February 6, 2025, NGS informed Petitioner that her opt-out status would be automatically renewed for another two-year period on May 18, 2025.  CMS Ex. 3.  The letter also informed Petitioner that she could cancel her opt-out status by notifying NGS at least 30 days prior to the end of the opt-out period.  Id.  Finally, the letter provided appeal rights for a supplier that failed to submit a timely notice to cancel opt-out status.  Id.

On March 10, 2025, Petitioner submitted two CMS-855I enrollment applications seeking to re-enroll in Medicare and to reassign benefits to her new employer, New York University.  P. Br. at 3.  Both of these applications were approved on March 18, 2025.  CMS Ex. 2 at 9-14, 17-22.

On June 25, 2025, Petitioner filed a reconsideration seeking to cancel her opt-out status effective May 18, 2025.  CMS Ex. 2 at 1.  In that same letter, Petitioner advised that she had initially sought to cancel her opt-out status on May 28, 2024.  Id.  Furthermore, Petitioner noted that two other re-enrollment applications were submitted on her behalf via the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) and subsequently approved.  Id.  Petitioner believed that based on conversations with the Medicare contractor, that those applications were sufficient to cancel her opt-out status "without needing to separately cancel the opt-out."  CMS Ex. 2 at 5.

In a reconsidered determination, dated August 29, 2025, the contractor hearing officer determined that, because Petitioner did not meet the deadline for cancelling her Medicare opt-out status, she would remain opted-out until at least May 18, 2027.  CMS Ex. 5 at 3-4.

Petitioner appealed, and the matter was initially before Administrative Law Judge (ALJ) Jacinta L. Alves.  The Civil Remedies Division issued ALJ Alves' standing prehearing order (Standing Order) on September 24, 2025.  The case was transferred to me on September 25, 2025.  Consistent with that order, CMS filed a motion for summary

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judgment and brief (CMS Br.) with five exhibits (CMS Exs. 1-5) and Petitioner filed a brief and response to the motion for summary judgment (P. Br.) with two exhibits (P. Exs. 1-2).  In the absence of any objections, I admit into evidence CMS Exs. 1-5 and P. Exs. 1-2.

Issues

Whether summary judgment is appropriate and whether CMS had a legitimate basis to deny Petitioner cancellation of her opt-out status.

Jurisdiction

I have jurisdiction to hear and decide this case.  42 C.F.R. §§ 405.450(a), 498.3(b)(19).

Discussion

1.  Summary judgment is appropriate.

CMS's determination that a physician failed to properly terminate or cancel his or her opt-out status is an initial determination that the physician may appeal pursuant to the review procedures at 42 C.F.R. § 498.  42 C.F.R. §§ 405.450(a); 498.3(b)(19); 498.5.  A physician dissatisfied with an initial determination may request reconsideration. 42 C.F.R. § 498.22.  A physician dissatisfied with a reconsidered determination is entitled to a hearing before an administrative law judge.  42 C.F.R. § 498.40.

CMS has moved for summary judgment.  In this case, Petitioner has not waived the right to oral hearing or otherwise consented to a decision based only upon the documentary evidence or pleadings.  Accordingly, disposition on the written record alone is not permissible, unless CMS's motion for summary judgment has merit.

Summary judgment is not automatic upon request but is limited to certain specific conditions.  The Secretary's regulations that establish the procedure for adjudicating Petitioner's case are at 42 C.F.R. pt. 498.  42 C.F.R. §§ 498.40, 498.42.  The regulations do not establish a summary judgment procedure or recognize such a procedure.  However, the Board has long accepted that summary judgment is an acceptable procedural device in cases adjudicated pursuant to 42 C.F.R. pt. 498.  See, e.g., Ill. Knights Templar Home, DAB No. 2274 at 3-4 (2009); Garden City Med. Clinic, DAB No. 1763 (2001); Everett Rehab. & Med. Ctr., DAB No. 1628 (1997).

Summary judgment is appropriate when there is no genuine dispute as to any issue of material fact for adjudication and/or the moving party is entitled to judgment as a matter of law.  In determining whether there are genuine issues of material fact for trial, the reviewer must view the evidence in the light most favorable to the non-moving party,

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drawing all reasonable inferences in that party's favor.  The party requesting summary judgment bears the burden of showing that there are no genuine issues of material fact for trial and/or that it is entitled to judgment as a matter of law.  Generally, the non-movant may not defeat an adequately supported summary judgment motion by relying upon the denials in its pleadings or briefs but must furnish evidence of a dispute concerning a material fact, i.e., a fact that would affect the outcome of the case if proven.  Mission Hosp. Reg'l Med. Ctr., DAB No. 2459 at 5 (2012) (and cases cited therein); Experts Are Us, Inc., DAB No. 2452 at 5 (2012) (and cases cited therein); Senior Rehab. & Skilled Nursing Ctr., DAB No. 2300 at 3 (2010) (and cases cited therein); see also Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248 (1986).

The standard for deciding a case on summary judgment and an ALJ's decision-making in deciding a summary judgment motion differ from resolving a case after a hearing.  On summary judgment, the ALJ does not make credibility determinations, weigh the evidence, or decide which inferences to draw from the evidence, as would be done when finding facts after a hearing on the record.  Rather, on summary judgment the ALJ construes the evidence in a light most favorable to the non-movant and does not decide which version of the facts is more likely true.  Holy Cross Vill. at Notre Dame, Inc., DAB No. 2291 at 5 (2009).  The Board also has recognized that on summary judgment it is appropriate for the ALJ to consider whether a rational trier of fact could find that the parties' evidence would be sufficient to meet that party's evidentiary burden.  Dumas Nursing and Rehab., L.P., DAB No. 2347 at 5 (2010).

The material facts in this case are not disputed, and there is no genuine dispute as to any material fact that requires a hearing.  Accordingly, summary judgment is appropriate.

2. Because the request to cancel was untimely, CMS properly denied Petitioner's request to cancel her opt-out status.  42 C.F.R. § 405.445.1

A physician or other practitioner may participate in the Medicare program as a supplier of services.  Social Security Act (Act) § 1861(d); 42 C.F.R. § 498.2.  A practitioner may also enter into one or more private contracts with Medicare beneficiaries "for the purpose of furnishing items or services that would otherwise be covered by Medicare" if certain conditions are met.  42 C.F.R. § 405.405(a).  Among those conditions, the practitioner must submit one or more affidavits opting out of the Medicare program.  42 C.F.R. § 405.405; see Act § 1802(b)(3).

If a practitioner opts out, Medicare will not pay for the services she provides to beneficiaries (except in emergency or urgent care circumstances).  42 C.F.R. §§ 405.405(e), 405.440(a), (d).  To opt out, the practitioner must sign an affidavit declaring that, during the two-year opt-out period, the practitioner will provide services to

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Medicare beneficiaries only through private contracts and will not submit claims for payment to Medicare or allow any entity to submit a Medicare claim on her behalf.  42 C.F.R. § 405.420.  The opt-out period is for two years, beginning on the effective date of the affidavit, in this case May 18, 2023.  42 C.F.R. §§ 405.400, 405.410.

A practitioner may cancel her opt-out status:

by submitting a written notice to each Medicare Administrative Contractor to which he or she would file claims absent the opt-out, not later than 30 days before the end of the current 2-year opt-out period, indicating that the physician or practitioner does not want to extend the application of the opt-out affidavit for a subsequent 2-year period.

42 C.F.R. § 405.445(a).

Petitioner does not dispute that she executed an opt-out affidavit on May 18, 2023, that her May 28, 2024 request to terminate that opt-out status was returned to her as untimely,2 or that she did not file another timely termination request.  Accordingly, Petitioner failed to comply with the requirements set forth in 42 C.F.R. § 405.445(a) and remains bound by the terms of her opt-out affidavit.

Instead, Petitioner attributes her untimely filing, in part, to having received incorrect information from the Medicare contractor.  See P. Br. at 3-4.  Specifically, Petitioner asserts that she initially attempted to cancel her opt-out status on May 28, 2024, but that request was denied as premature.  See Request for Hearing at 1.  Petitioner subsequently submitted two CMS-855I enrollment applications on March 10, 2025, seeking to re-enroll in Medicare and to reassign benefits to her new employer, New York University.  P. Br. at 3.  During a telephone conversation with the Medicare contractor on March 13, 2025, Petitioner was advised that no further action was required beyond submission of those applications.  Id.  Relying on that information, Petitioner believed that her Medicare participation would be reinstated without the need to separately cancel her opt-out status.  Id.

Although those applications were later approved (CMS Ex. 2 at 9-14, 17-22), such approval—presumably limited to emergency services—did not alter Petitioner's opt-out status because she did not submit a timely cancellation request as required by regulation.

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In her reconsideration request, Petitioner acknowledged that her failure to timely cancel her opt-out status "was an honest oversight resulting from incorrect guidance received from PECOS."  CMS Ex. 2 at 1.  Nevertheless, Petitioner bears the responsibility of familiarizing herself with applicable Medicare statutes and regulations.  Moreover, the correspondence issued to Petitioner following both her initial opt-out election and subsequent renewal included instructions regarding the procedures and timing requirements for proper cancellation.  CMS Exs. 1, 3.

Petitioner's arguments are, in essence, a request for equitable relief—namely, that CMS should be estopped from enforcing the renewal of her opt-out period due to the alleged misinformation she received.  However, I lack authority to grant such relief by disregarding governing statutes and regulations.  See Parvin Shafa, M.D., Inc., DAB No. 2846 at 8 (2018); Thomas Macari, D.O., DAB CR3155 at 4 (2014).

Furthermore, even if equitable considerations were properly before me, Petitioner has not demonstrated circumstances that would warrant such relief.  Petitioner does not allege that the applicable regulations are unclear or ambiguous; indeed, they are unambiguous on their face.  Nor has Petitioner established that CMS engaged in affirmative misconduct, such as fraud, which is generally required to support a claim of equitable estoppel against the government.  See, e.g., Richard Weinberger, M.D. and Barbara Vizy, M.D., DAB No. 2823 at 19 (2017) (citing Office of Personnel Management v. Richmond, 496 U.S. 414, 419-21 (1990)).  Absent such a showing, equitable estoppel does not lie.

Finally, I do not have authority to enroll or reimburse a physician who fails to satisfy statutory and regulatory requirements.  Granting Petitioner the relief she seeks would effectively create a mechanism for early termination of an opt-out agreement that is not recognized under applicable law.  Accordingly, Petitioner's arguments do not provide a basis for relief.

Conclusion

Because the undisputed evidence establishes that Petitioner did not meet the requirements for timely cancelling her opt-out status, CMS properly denied her request for cancellation.  I therefore grant CMS's motion for summary judgment.