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 rules say that items and services furnished outside the United States are not covered. The US includes the 50 States, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, and The Northern Mariana Islands. The US also includes the territorial waters adjoining the land areas of the US. Services furnished on board ship are considered to have been furnished in US territorial waters if they were furnished while the ship was in a port of one of the jurisdictions listed above, or within 6 hours before arrival at, or 6 hours after departure from, such a port. Medicare may pay for inpatient hospital services you get in a foreign country. Medicare may pay for doctor or ambulance services related to covered inpatient hospital stays in a foreign country. These services may be covered only in the following cases: 1. If an emergency arose within the US and the foreign hospital is closer than the nearest US hospital that can treat your medical condition,
2. If you are traveling through Canada without unreasonable delay by the most direct route between Alaska and another state when a medical emergency occurs and the Canadian hospital is closer than the nearest US hospital that can treat the emergency, 3. If you live in the US and the foreign hospital is closer to your home than the nearest US hospital that can treat your medical condition, regardless of whether an emergency exists. You can find these rules at 42 CFR  411.9 and 424.121 - 424.124. The rules say that Medicare generally does not cover items and services furnished outside of the United States. You can find this rule at 42 CFR 411.9 and Medicare Benefit Policy Manual, Chapter 16 60. The rules say that the health plan must pay for emergency and urgently needed services. This rule applies whether the services are obtained in or out of the health plan's network. This rule applies whether or not there is prior authorization for the services. The rules say that an emergency is defined as when a prudent layperson would believe that without immediate medical attention there would be serious jeopardy to his or her health. The 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 health plan. Generally, these services are needed while the enrollee is outside of the service area. You can find this rule at 42 CFR 422.113. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the health plan sufficient information to determine whether payment is due and the amount of payment. You can find this rule at 42 CFR Section 424.5.
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. The Plan contract says you are covered for emergency care worldwide. If you have an emergency outside of the U.S. and its territories, you are responsible to pay for the services upfront. You must submit proof of payment, copies of medical records, contact information for the providers rendering the services and all supporting documentation to the plan for reimbursement within 12 months from the date of service. We may not reimburse you for all out of pocket expenses. The plan will only reimburse up to the Medicare allowable rates. You can find this information on page 64 of the Plan's 2020 Evidence of Coverage and on page 44 of the Plan's 2021 Evidence of Coverage.