Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay an additional $796.70 for the laboratory tests provided on August 16, 2022, 
genetic testing provided on September 3, 2022, laboratory tests provided on September 13, 2022, and laboratory tests provided on September 14, 2022. We decided that the Plan does not have to pay for the clinic 
service, CT scan, and visit provided on August 17, 2022, specialty/subspecialty hospital stay provided from 
August 17, 2022, to August 19, 2022, visit provided on August 24, 2022, clinic visit provided on September 12, 
2022, doppler scans and medical supplies provided on September 13, 2022, visit, EKG, lung spirometry, and 
medication injection provided on September 14, 2022, visit provided on September 15, 2022, radiogram, 
oximetry, specialist visits, and clinic fee provided on September 20, 2022, visit provided on September 24, 
2022, clinic visit and pharmacy charges provided on September 26, 2022, and spirometry with unknown DOS.  
 
You asked the Plan to pay for the laboratory tests provided on August 16, 2022, clinic service CT scan, and 
visit provided on August 17, 2022, specialty/subspecialty hospital stay provided from August 17, 2022, to 
August 19, 2022, visit provided on August 24, 2022, genetic testing provided on September 3, 2022, clinic visit 
provided on September 12, 2022, laboratory tests, doppler scans, and medical supplies provided on September 
13, 2022, laboratory tests, visit, EKG, lung spirometry, and medication injection provided on September 14, 
2022, visit provided on September 15, 2022, radiogram, oximetry, specialist visits, and clinic fee provided on 
September 20, 2022, visit provided on September 24, 2022, clinic visit and pharmacy charges provided on 
September 26, 2022, and spirometry with unknown DOS. You say that this was an extreme emergency, and 
you were forced to borrow money from family and friends for life-saving treatment. The Plan says that medical 
records and receipts need to be provided for the remaining care with other date ranges. 
 
We decided that the Plan has to pay an additional $796.70 for the laboratory tests provided on August 
16, 2022, genetic testing provided on September 3, 2022, laboratory tests provided on September 13, 
2022, and laboratory tests provided on September 14, 2022.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside the United 
States are excluded from coverage except for certain services. 
 
We looked at the file and Medicare rules. The contract clearly states that you must first pay for medical care 
received, obtain a discharge summary or equivalent medical documentation and proof of payment, and submit 
this information to the Plan. Specifically record shows that both medical records and receipts of payment were 
submitted for these services. Therefore, we decided that the Plan has to pay an additional $796.70 for the 
laboratory tests provided on August 16, 2022, genetic testing provided on September 3, 2022, laboratory tests 
provided on September 13, 2022, and laboratory tests provided on September 14, 2022.  
 
We also decided that the Plan does not have to pay for the clinic service, CT scan, and visit provided on 
August 17, 2022, specialty/subspecialty hospital stay provided from August 17, 2022, to August 19, 2022, 
visit provided on August 24, 2022, clinic visit provided on September 12, 2022, doppler scans and 
medical supplies provided on September 13, 2022, visit, EKG, lung spirometry, and medication injection 
provided on September 14, 2022, visit provided on September 15, 2022, radiogram, oximetry, specialist 
visits, and clinic fee provided on September 20, 2022, visit provided on September 24, 2022, clinic visit 
and pharmacy charges provided on September 26, 2022, and spirometry with unknown DOS. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside the United 
States are excluded from coverage except for certain services. The rules also say that Medicare Part B generally 
does not pay for self-administered drugs. 
 
 
  We looked at the file and Medicare rules. The contract clearly states that you must first pay for medical care 
received, obtain a discharge summary or equivalent medical documentation and proof of payment, and submit 
this information to the Plan. The record shows that medical records and a payment receipt were not submitted 
for these services. The pharmacy charges requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the clinic service, CT scan, and 
visit provided on August 17, 2022, specialty/subspecialty hospital stay provided from August 17, 2022, to 
August 19, 2022, visit provided on August 24, 2022, clinic visit provided on September 12, 2022, doppler 
scans and medical supplies provided on September 13, 2022, visit, EKG, lung spirometry, and medication 
injection provided on September 14, 2022, visit provided on September 15, 2022, radiogram, oximetry, 
specialist visits, and clinic fee provided on September 20, 2022, visit provided on September 24, 2022, clinic 
visit and pharmacy charges provided on September 26, 2022, and spirometry with unknown DOS. 
 
Benefits for the pharmacy charges provided on September 26, 2022, may be available under Medicare Part D. 
Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal 
rights. 
 
 
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.