Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0483) 
provided to the enrollee on July 5, 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 the documentation does not indicate the specific lab test ordered by the provider 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 
 
HCPCS G0483: 
 
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; 22 or more 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 reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found per CMS 
guidelines, All diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by 
the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a 
beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's 
specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable 
and necessary. The documentation does not show any evidence of an established relationship between the 
enrollee and the ordering physician. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on July 5, 2019.