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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 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. 
 
The rules say that a Medicare Plan is financially responsible for emergency services regardless of whether the 
services are obtained within or outside the Plan. Emergency services are covered whether there is prior 
authorization for the services. An emergency is defined as when a person would believe that without immediate 
medical attention there would be serious jeopardy to his or her health. You can find this rule at 42 CFR Section 
422.113(b). 
 
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 the Plan covers worldwide emergency and urgent care services outside of the United States 
under the following circumstances: 
- Emergency care 
- Urgently needed care 
- Emergency ambulance transportation from the scene of an emergency to the nearest medical treatment 
facility 
 
Transportation back to the United States from another country is not covered. Pre-scheduled and/or elective 
procedures are not covered. Be sure to get a copy of all your medical records from your emergency or urgent 
care provider before you leave; you may need them to file a claim or to help with claims processing. Without 
these records the Plan may not be able to pay your claim. You can find this information in Chapter 3 on pages 
25 to 26 of the Plans 2023 Evidence of Coverage.