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 CFR 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:&#61623;Emergency inpatient hospital services where the emergency occurred: While the beneficiary was physically present in the United States; oro In Canada while the beneficiary was traveling without reasonable delay and by the most direct route between Alaska and another State.&#61623;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;&#61623;Physician and ambulance services furnished in connection with a covered foreign hospitalization. Payment may not be made for any other Part B medical and other health services, including outpatient services furnished outside the United States; &#61623;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 for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. You can seethis in the Medicare Program Integrity Manual Chapter 3  3.3.2.1.The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. You can find this rule at 42 CFR 424.5.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. ThePlan contract says that enrollees are covered for emergency or urgently needed care worldwide. If you have a medical urgency outside of the United States and its territories, you will be responsible to pay for the services rendered up front. You must submit proof of payment, copies of medical records, contact information for the providers rendering the services, and all other supporting documentation to the Plan within 12 months from the date of service for reimbursement. The Plan may not reimburse you forall out-of-pocket expenses. This is 
because the Plan's rates may be lower than providers outside of the United States and its territories. The Plan will only reimburse Medicare allowable rates. You can find this information in Chapter 4 on page 84 of the Plan's 2019 Evidence of Coverage.