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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: 
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. See Pub. 100-04, Medicare Claims Processing Manual Chapter 3, Inpatient Hospital 
Billing,Section 110 for a description of claims processing procedures. 
 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 beneficiarys 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 (see Pub. 100-04, Medicare Claims Processing Manual 
Chapter 3, Inpatient Hospital Billing, Section 110 for a description of claims processing procedures); 
 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 (see Pub. 100-04, Medicare Claims Processing Manual Chapter 1, General 
Billing Requirements, Section 10.1.4.1 for a description of claims processing procedures); 
 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 (see Pub. 100-04, Medicare Claims Processing Manual Chapter 1, General 
Billing Requirements, Section 10.1.4.7 for a description of claims processing procedures); 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.  
 
A hospital that is not physically situated in one of the above jurisdictions is considered to be outside the United 
States, even if it is owned or operated by the United States Government.  
Payment may not be made for any item provided or delivered to the beneficiary outside the United States, even 
though the beneficiary may have contracted to purchase the item while they were within the United States or 
purchased the item from an American firm. 
 
Payment may not be made for a medical service (or a portion of it) that was subcontracted to another provider 
or supplier located outside the United States. For example, if a radiologist who practices in India analyzes 
imaging tests that were performed on a beneficiary in the United States, Medicare would not pay the radiologist 
or the U.S. facility that performed the imaging test for any of the services that were performed by the 
radiologist in India. 
 
Under the Railroad Retirement Act, payment is made to Qualified Railroad Retirement beneficiaries (QRRBs) 
by the RRB for covered hospital services furnished in Canadian hospitals as well as in the U.S. Physician and 
ambulance services are not covered by the Railroad Retirement Act; however, under an agreement between 
CMS and RRB, if the QRRB claims payment for Part B services in connection with Canadian hospitalization, 
RRB processes the Part B claim. In such cases the RRB determines: 
 Whether the requirements are met for the inpatient services; and 
 Whether the physician and/or ambulance services were furnished in connection 
with the services. 
 
Services for an individual who has elected religious nonmedical health care status may be covered if the above 
requirements are met but this revokes the religious nonmedical health care institution election. 
 
You can find this information in the Medicare Benefit Policy Manual Chapter 16  General Exclusions From 
Coverage, Section 60 - Services Not Provided Within United States. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.