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 Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
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: 
        - 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. 
 
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 contract 
says that the Plan covers worldwide emergency and urgent care services outside of the United States (U.S.) 
under the following circumstances. If you have an emergency or an urgent need for care outside of the U.S. and 
its territories, you will be responsible to pay for those services upfront and request appropriate reimbursement 
from the Plan. The Plan will reimburse you, for covered out-of-network emergency and urgent care services 
outside of the U.S. and its territories, at rates no greater than the rates at which Original Medicare would pay 
for such services had the services been performed in the United States in the locality where you reside. The 
amount the Plan pays you, if any, will be reduced by any applicable cost-sharing. Because the Plan will 
reimburse at rates no greater than the rates at which Original Medicare would reimburse, and because foreign 
providers might charge more for services than the rates at which Original Medicare would pay, the total of the 
Plan's reimbursement plus the applicable cost-sharing may be less than the amounts you pay the foreign 
provider. This is a supplemental benefit not generally covered by Medicare. You must submit proof of payment 
to the Plan for reimbursement. If you have already paid for the covered services, the Plan will reimburse you 
for the Plan's share of the cost for covered services. You can send the bill with medical records to the Plan for 
payment consideration. You can find this information on page 40 of the Plan's 2023 Evidence of Coverage.