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:  
          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 does not cover out-of-network services rendered with the exceptions of the following: 
   Emergency care or urgently needed services that you get from an out-of-network provider. This includes 
worldwide coverage if covered by your plan. 
   If you need medical care that Medicare requires our plan to cover and providers in our network cannot 
provide this care, you can get this care from an out-of-network provider. For these types of referrals you must 
obtain authorization before seeking care. Your PCP can assist you with obtaining authorization. In this 
situation, we will cover these services as if you got the care from a network provider. If you do not have a prior 
authorization before you receive services from an out-of-network provider, you may have to pay for these 
services yourself. 
   Renal dialysis services when you are temporarily outside the service area, or when prior authorized. 
You can find this information on page 52 of the Plan's 2021-2022 Evidence of Coverage. 
 
The contract also says that the Plan's Travel Assurance is available for members while traveling. This includes 
worldwide coverage for services needed to evaluate or stabilize an emergency medical condition. You can find 
this information on page 76 of the Plan's 2021-2022 Evidence of Coverage.