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 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. 
 
The rules say 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 Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
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:  
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. 
 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 the Plan covers worldwide emergency and urgent care services outside of the United States 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 our 
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. You can find this information on page 47 of the Plan's 2022 Evidence of Coverage.