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 state 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: oWhile the beneficiary was physically present in the United States; or oIn 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 (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 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 (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); 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 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 contract states that the Plan covers worldwide emergency and urgent care services outside the United States under the following circumstances: -You have a reasonable belief that the services that you are getting are to treat a serious injury or condition that requires immediate attention; -You pay for the services upfront; -You submit a request for reimbursement along with a receipt or proof of payment and copies of the medical documentation in English. You can find this information on page 47 of the Plan's 3030 EOC.