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: oWhile the beneficiary was physically present in the United States; oroIn 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;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 see this 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 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 you are covered for emergency and urgently-needed services worldwide. Services received must meet the same Medicare criteria applied to emergency or urgent care services received within the United States and its territories. You are covered for worldwide emergency transportation by ambulance to go to the nearest appropriate facility that can provide care, if the service is furnished when your medical condition is such that other means of transportation could endanger your health, or if authorized by the Plan. You can find this information in Chapter 4 on page 52 of the Plan's 2019 Evidence of Coverage.