Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing services provided to the enrollee on December 23, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says that the records do not support the service billed, as the documentation did not include a
physician order/lab requisition or medical records stating exactly what tests were to be performed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of
the denied codes is:
CPT 80307:
Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, by
instrument chemistry and analyzers (e.g., utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]),
chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (DAT,
DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when
performed, per date of service (maps to 80301, 80302, 80303, 80304 and G0479
HCPCS G0482:
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms
(any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia,
elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g.,
to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes
specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the services. Our reviewers says that the
services at issue in this case were supported by the medical records. Our physician reviewer found the Custom
Toxicology Profile in the case file has Full Presumptive Screening checked, as well as Custom testing. The
results of the testing is in the case file. The coding of CPT 80307, Drug test(s), presumptive, is supported by
the information in the case file. The coding HCPCS G0482, Drug test(s), definitive, is supported by the
information in the case file.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for
drug testing services provided to the enrollee on December 23, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.