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, generally, items and services provided outside of the United States (US) are not covered. 
The only exceptions are emergency hospital services when the emergency occurred within the US, 
emergency/non-emergency hospital services when the foreign hospital is substantially closer or more 
accessible than the US hospital, or services provided on a ship docked at a US port or within US Territorial 
waters. You can find this information in the Centers for Medicare and Medicaid Services, Internet-Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 60. 
 
The rules say that an ambulance transport is covered to the nearest appropriate facility to obtain necessary 
diagnostic and/or therapeutic services. Only local transportation by ambulance is covered, and therefore, only 
mileage to the nearest appropriate facility equipped to treat the patient is covered.  
 
The term "locality" with respect to ambulance service means the service area surrounding the institution to 
which individuals normally travel or are expected to travel to receive hospital or skilled nursing services. The 
MACs have the discretion to define locality in their service areas. 
 
The term "appropriate facilities" means that the institution is generally equipped to provide the needed hospital 
or skilled nursing care for the illness or injury involved. In the case of a hospital, it also means that a physician 
or a physician specialist is available to provide the necessary care required to treat the patient's condition. The 
fact that a more distant institution is better equipped, either qualitatively or quantitatively, to care for the patient 
does not warrant a finding that a closer institution does not have "appropriate facilities." Such a finding is 
warranted, however, if the beneficiary's condition requires a higher level of trauma care or other specialized 
service available only at the more distant hospital. 
 
You can find this information in the Centers for Medicare and Medicaid Service, Internet-Only Manual, 
Publication 100-02, Medicare Benefit Policy Manual, Chapter 10, Section 10.3, 10.3.5, and 10.3.6. 
 
The rules say that Medicare pays for air ambulance services only if the enrollees medical condition is such that 
transportation by either basic, the provision of medically necessary supplies and services or advanced life support, an emergency medical technician (EMT) intermediate or EMT-Paramedic ground ambulance is not 
appropriate. Air ambulance services may be covered only if: 
 
1. certain vehicle and crew requirements are met; 
 
2. the enrollees medical condition needed immediate and rapid ambulance transport that could not have been 
provided by ground ambulance; and  
 
3. either the point of pickup is not accessible by ground vehicle or great distances or other obstacles are 
involved in getting the patient to the nearest hospital with appropriate facilities. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-02, Medicare Benefit Policy Manual, Chapter 10, Sections 10.4, and 10.4.1, and 30.1.1. 
 
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, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. The Plan contract says that they cover worldwide emergency 
and urgent care services outside of the United States when you are only temporarily outside of the service area, 
when the services were necessary to treat an unforeseen illness or injury to prevent serious deterioration of your 
health, when it was not reasonable to delay treatment until you returned to the service area, and when the 
services would have been covered had you received them from a network provider. You can find this 
information on pages 12 and 40 of the Plan's 2023 Evidence of Coverage.