Appeal type: unknown
Decision: unknown

The rules say that plans must pay fora 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 an emergency is defined as when a prudent layperson would believe that withoutimmediate 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.The rules also 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:o While the beneficiary was physically present in the United States; or o In Canada while the beneficiary was traveling without reasonable delay and by the most direct route between Alaska and another State.  See Pub. 100-04, Medicare Claims Processing Manual Chapter 3, Inpatient Hospital Billing, Section 110 for a description of claims processing procedures.-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 UnitedStates hospital which was adequately equipped to deal with nd available to provide treatment of the illness or injury (see Pub. 100-04, Medicare Claims Processing Manual Chapter 3, Inpatient Hospital Billing, Section 110 for a description of claims processing procedures);-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 (see Pub. 100-04, Medicare Claims Processing Manual Chapter 1, General Billing Requirements, Section 10.1.4.1 for a description of claims processing procedures);-Services rendered on board a ship in a United States port, or within 6 hoursof 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 (see Pub. 100-04, Medicare Claims Processing Manual Chapter 1, General Billing Requirements, Section 10.1.4.7 for a description of claims processing procedures).You can find these rules in The Medicare Benefit Policy Manual, Chapter 16, Section 60.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 states that it covers worldwide emergency care. You can find this information on pages 67 to 68 of the Plan's 2019 EOC