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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 say that Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
Prior to January 1, 2023, the American Medical Association's Current Procedural Terminology (CPT) used new 
patient codes 99324 - 99328 and established patient codes 99334 - 99337 for Domiciliary, Rest Home (e.g., 
Boarding Home), or Custodial Care Services, to report evaluation and management (E/M) services to residents 
residing in a facility which provides room, board, and other personal assistance services, generally on a long-
term basis. These CPT codes were used to report E/M services in facilities assigned places of service (POS) 
codes 13 (Assisted Living Facility), 14 (Group Home), 33 (Custodial Care Facility) and 55 (Residential 
Substance Abuse Treatment Facility). Assisted living facilities may also be known as adult living facilities. The 
CPT codes 99324 - 99337 for Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services are 
deleted beginning January 1, 2023. 
 
Beginning January 1, 2023, the CPT is merging the two E/M visit families currently titled "Domiciliary, Rest 
Home (e.g., Boarding Home), or Custodial Care Services" and "Home Services." The new family will be titled 
"Home or Residence Services. The codes in this family (CPT codes 99341 - 99350) will be used to report E/M 
services furnished to a patient residing in their home, in an assisted living facility, in a group home (that is not 
licensed as an intermediate care facility for individuals with intellectual disabilities), in a custodial care facility, 
or in a residential substance abuse treatment facility. There are no changes to the included care settings from 
each respective family, rather the current care settings for each of the current families are being included within 
the new, merged family. For services in an intermediate care facility for individuals with intellectual disabilities 
and services provided in a psychiatric residential treatment center, see Nursing Facility Services in Section 
30.6.13. 
 
Physicians and qualified nonphysician practitioners (NPPs) furnishing E/M services to residents in a living 
arrangement described by one of the POS listed above must use the level of service code in the CPT code range 
99341 - 99350 to report the service they provide.  
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.14 
 
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.