Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the medical services provided outside of the United States on June 21, 
2022. We decided that the Plan does not have to pay for the medical services provided outside of the United 
States on March 26, 2021, July 8, 2021, September 30, 2021, January 17, 2022, March 11, 2022, April 27, 
2022, November 9, 2022, November 17, 2022, and November 25, 2022.  
 
You asked the Plan to pay for medical services provided outside of the United States on March 26, 2021, 
through November 25, 2022. You say that you are overseas in Indonesia and have been stuck there due to 
COVID restrictions and because you've been sick. You say that you have submitted claims for services 
provided out of the country before, provided the same type of documentation, and received coverage. You say 
that Indonesia is a third world country and they do not provide the same paperwork as in the United States. The 
Plan says that the documentation provided does not show medical necessity. 
 
We decided that the Plan has to pay for the medical services provided outside of the United States on 
June 21, 2022.  
 
The Plan follows Medicare rules. Medicare rules say that urgently needed services are those needed because of 
an unforeseen illness or condition, and it is not reasonable to get the services from the Plan. The Plan contract 
says that they will pay for urgent care received outside of the United States when medically necessary and 
appropriate.  
 
The documentation provided included sufficient medical records from date of service June 21, 2022, to support 
that the services provided were urgent in nature. Therefore, we decided that the Plan has to pay for the medical 
services provided outside of the United States on June 21, 2022.  
 
We also decided that the Plan does not have to pay for the medical services provided outside of the 
United States on March 26, 2021, July 8, 2021, September 30, 2021, January 17, 2022, March 11, 2022, 
April 27, 2022, November 9, 2022, November 17, 2022, and November 25, 2022. 
 
The Plan follows Medicare rules. Medicare rules say that items and services provided outside of the United 
States are generally not covered. The only exceptions are emergency hospital services when the emergency 
occurred within the US, emergency/non-emergency hospital services when the foreign hospital is substantially 
closer or more accessible than the US hospital, or services provided on a ship docked at a US port or within US 
Territorial waters. However, the Plan offers coverage for emergency, urgent care, and emergency transportation 
received outside the United States when documentation is provided to support medical necessity and 
appropriateness.  
 
The documentation provided did not include any medical records for dates of service March 26, 2021, July 8, 
2021, September 30, 2021, January 17, 2022, March 11, 2022, April 27, 2022, November 9, 2022, November 
17, 2022, and November 25, 2022. The only documentation pertaining to these dates of service were invoices 
showing the charges billed. This does not allow for review of medical necessity and appropriateness. 
Therefore, we decided that the Plan does not have to pay for the medical services provided outside of the United States on March 26, 2021, July 8, 2021, September 30, 2021, January 17, 2022, March 11, 2022, April 
27, 2022, November 9, 2022, November 17, 2022, and November 25, 2022. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.