Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0483 provided on May 5, 2022. 
 
You asked the Plan to pay for the drug testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are not supported. 
 
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 code G0483 is 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 find that CPT code G0483 is not supported in the medical record. Specifically, the diagnosis billed is 
medication management of long term (current) drug therapy. The medical records submitted show screening 
test results which are positive or inconsistent with prescription medications, or history and expected results. 
Definitive confirmation testing was medically necessary for only 3 drug class(es): Benzodiazepines; Opiates; 
Oxycodone. The Medicare rules say definitive testing is covered only under certain conditions: When the 
results of the screen are presumptively positive; when the results of the screen are negative and this negative 
finding is inconsistent with the medical history; and this test may also be used, when the coverage criteria of 
the policy are met AND there is no presumptive test available, locally and/or commercially, as may be the case 
for certain synthetic or semi-synthetic opioids. National pain management organizations, physician societies, 
and the Federation of State Medical Boards recommend a practical approach to definitive urine drug testing. In 
all cases, the number of drug classes tested should reflect only those likely to be present based on the medical 
history, current clinical presentation, and the illicit drugs that are in common use. In other words, it is not 
medically necessary to routinely test for drug classes which are not used to treat the patient, or in the instance 
of illicit drugs, in the community at large. The use of confirmatory testing should be based on the need to detect 
specific drug metabolites that cannot be identified on standard immunoassays, or on the presence of unexpected 
presumptive urine drug test results. In addition, clinicians should not test for substances when the results would 
not affect patient management, or for which implications for patient management are unclear. Each individual 
definitive drug class tested must be medically necessary, and the results of each drug class tested must be used 
to treat an active illness or disease, as opposed to being used for screening purposes. Ordering a multi-drug 
panel of definitive (confirmation) urine drug tests that are not used in management of the member is not 
medically necessary. Based on this information, we decided that Medicare rules for coverage of the drug 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 
G0483 provided on May 5, 2022.