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 excluded from coverage except for the following services, and certain services rendered on board a ship:
Emergency inpatient hospital services where the emergency occurred:
~ While the beneficiary was physically present in the United States; or
~ In Canada while the beneficiary was traveling without reasonable delay and by the most direct route between Alaska and another State.
- Emergency or nonemergency inpatient hospital services furnished by a hospital located outside the United States, if the hospital was closer to, or substantially more accessible from, the beneficiary's United States residence than the nearest participating United States hospital which was adequately equipped to deal with and available to provide treatment of the illness or injury;
- Physician and ambulance services furnished in connection with a covered foreign hospitalization. Program payment may not be made for any other Part B medical and other health services, including outpatient services furnished outside the United States;
- Services rendered on board a ship in a United States port, or within 6 hours of when the ship arrived at, or departed from, a United States port, are considered to have been furnished in United States territorial waters. Services not furnished in a United States port, or within 6 hours of when the ship arrived at, or departed from, a United States port, are considered to have been furnished outside United States territorial waters, even if the ship is of United States registry; and
The term "United States" means the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, American Samoa and, for purposes of services rendered on a ship, includes the territorial waters adjoining the land areas of the United States. You can find these rules in Medicare Benefit Policy Manual Chapter 16, Section 60.
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112.
The rules say that the plan must pay for emergency and urgently needed services. This rule applies whether the services are obtained in or out of the 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 plan. Generally, these services are needed while the enrollee is outside of the service area. You can find this rule at 42 CFR Section 422.113.
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 that the Plan covers worldwide emergency/urgent care. This coverage is limited to services that would be classified as emergency, urgently needed, or post-stabilization care had they been provided in the United States. Foreign taxes and fees are not covered. Enrollees pay $0 copayment for each worldwide emergency care, urgent care, and transportation service received outside of the United States, up to an annual limit of $50,000. You can find this information in Chapter 4 on page 95 of the Plan's 2020 Evidence of Coverage.