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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 Medicare guidelines say "B. Hospital Discharge Day Management Service Hospital Discharge Day
Management Services, CPT code 99238 or 99239 is a face-to face evaluation and management (E/M) service
between the attending physician and the patient. The E/M discharge day management visit shall be reported for
the date of the actual visit by the physician or qualified non physician practitioner even if the patient is
discharged from the facility on a different calendar date. Only one hospital discharge day management service
is payable per patient per hospital stay. D. Hospital Discharge Management (CPT Codes 99238 and 99239) and
Nursing Facility Admission Code When Patient Is Discharged from Hospital and Admitted to Nursing Facility
on Same Day: A/B MACs (B) pay the hospital discharge code (codes 99238 or 99239) in addition to a nursing
facility admission code when they are billed by the same physician with the same date of service. If a surgeon
is admitting the patient to the nursing facility due to a condition that is not as a result of the surgery during the
postoperative period of a service with the global surgical period, he/she bills for the nursing facility admission
and care with a modifier "-24" and provides documentation that the service is unrelated to the surgery (e.g.,
return of an elderly patient to the nursing facility in which he/she has resided for five years following discharge
from the hospital for cholecystectomy). A/B MACs (B) do not pay for a nursing facility admission by a
surgeon in the postoperative period of a procedure with a global surgical period if the patient's admission to the
nursing facility is to receive post-operative care related to the surgery (e.g., admission to a nursing facility to
receive physical therapy following a hip replacement). Payment for the nursing facility admission and
subsequent nursing facility services are included in the global fee and cannot be paid separately. E. Hospital
Discharge Management and Death Pronouncement: Only the physician who personally performs the
pronouncement of death shall bill for the face-to-face Hospital Discharge Day Management Service, CPT code
99238 or 99239. The date of the pronouncement shall reflect the calendar date of service on the day it was
performed even if the paperwork is delayed to a subsequent date." You can find this guidance in the Medicare
Claims Processing Manual CMS Chapter 12 - Physicians/Nonphysician Practitioners Sec-30.6.9.2 - Subsequent
Hospital Visits and Hospital Discharge Day Management Services (Codes 99231 - 99239).
The Medicare guidelines say "The A/B MACs (A) must provide a listing of the required data elements,
including a brief explanation to providers and suppliers. A/B MACs (A) must educate providers regarding the
distinction between submissions which are not considered claims, but which are returned to provider (RTP) and
submissions which are accepted by Medicare as claims for processing but are not paid. Claims may be accepted
as filed by Medicare systems but may be rejected or denied. Unlike RTPs, rejections and denials are reflected
on RAs. Denials are subject to appeal, since a denial is a payment determination. Rejections may be corrected
and resubmitted." You can find this guidance in the Medicare Claims Processing Manual Chapter 1 - General
Billing Requirements Section 70.2.3.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com