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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 providers must report services correctly. Procedures should be reported with the Current 
Procedural Terminology (CPT) code that describes the services performed. You can find this rule in the 
Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that for drug testing, although technology has provided the ability to measure many toxins, most 
toxicological diagnoses and therapeutic decisions are made based on historical or clinical considerations: 
Laboratory turnaround time can often be longer than the critical intervention time course of an overdose.         
The cost and support of maintaining the instruments, staff training, and specialized labor involved in some 
analyses are prohibitive. For many toxins, there are no established cutoff levels of toxicity, making 
interpretation of the results difficult. Although comprehensive screening is unlikely to affect emergency 
management, the results may assist the admitting physicians in evaluating the patient if the diagnosis remains 
unclear. Screening panels should be used when the results will alter patient management or disposition. 
A qualitative/presumptive drug test may be indicated for a variety of reasons including the following: A 
symptomatic patient when the history is unreliable, when there has been a suspected multiple-drug ingestion, to 
determine the cause of delirium or coma, or for the identification of specific drugs that may indicate when 
antagonists may be used. For monitoring patient compliance during active treatment for substance abuse or 
dependence. To monitor for compliance/adherence to the treatment plan or illicit drug use in patients under 
treatment or seeking treatment for a chronic pain condition. The clinical utility of drug tests in the emergency 
setting may be limited because patient management decisions are unaffected, since most therapy for drug 
poisonings is symptom directed and supportive.  
 
 
 Medicare will consider performance of a qualitative presumptive drug test reasonable and necessary when a 
patient presents with suspected drug overdose and one or more of the following conditions: Unexplained coma, 
Unexplained altered mental status in the absence of a clinically defined toxic syndrome or toxidrome, severe or 
unexplained cardiovascular instability (cardiotoxicity), Unexplained metabolic or respiratory acidosis in the 
absence of a clinically defined toxic syndrome or toxidrome. Testing on neonates suspected of prenatal drug 
exposure, Seizures with an undetermined history. Medicare will consider performance of a 
qualitative/presumptive drug test reasonable and necessary when a patient presents with one or more of the 
following conditions: For monitoring patient compliance during active treatment for substance abuse or 
dependence. A drug screen is considered medically reasonable and necessary in patients on chronic opioid 
therapy: In whom illicit drug use, non-compliance, or a significant pre-test probability of non-adherence to the 
prescribed drug regimen is suspected and documented in the medical record; and/or in those who are at high 
risk for medication abuse due to psychiatric issues, who have engaged in aberrant drug-related behaviors, or 
who have a history of substance abuse. Medicare will consider performance of a drug test reasonable and 
necessary in patients with chronic pain to: determine the presence of other substances prior to initiating 
pharmacologic treatment detect the presence of illicit drugs 
monitor adherence to the plan of care. Drugs, or drug classes for which testing is performed, should reflect only 
those likely to be present, based on the patient's medical history, current clinical presentation, and illicit drugs 
that are in common use. Drugs for which specimens are being tested must be indicated by the referring provider 
in a written order. A drug test may be reasonable and necessary for patients with known substance abuse or 
dependence, only when the clinical presentation has changed unexpectedly and one of the above indications is 
met. A drug test may be reasonable and necessary for patients with symptoms of schizophrenia suspected to be 
secondary to drug or substance intoxication. Definitive drug testing is indicated when: The results of the screen 
are presumptively positive. Results of the screen are negative, and this negative finding is inconsistent with the 
patient's medical history. 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. A positive screen often results in an inadequate result upon which to make a proper 
determination. A more specific method, such as gas or liquid chromatography coupled with mass spectrometry, 
may be needed to obtain a confirmed analytical result. In particular, screens are frequently inadequate for 
interpretation of opiate and benzodiazepine results. Therefore, quantitative testing may be needed in these 
instances. Confirmation testing is usually not required for drugs like methadone, wherein false positive results 
are rare. However, factors such as cross-reactivity with other similar compounds or interfering substances in 
the specimen may affect test results. Confirmatory testing eliminates the risk of false positives. Also, 
eliminated by confirmation, is the risk of a ?pill scraper? slipping through. Patients diverting their drug, attempt 
to cheat the test by scraping a bit of drug from a pill into their urine sample. It would screen positive, but there 
would be no metabolite upon confirmation. Frequent use of this code will be monitored for appropriateness.  
Limitations: It is considered not reasonable or necessary to test for the same drug with both a blood and a urine 
specimen simultaneously. Drug screening for medico-legal purposes (e.g., court-ordered drug screening) or for 
employment purposes (e.g., as a pre-requisite for employment or as a requirement for continuation of 
employment) are not covered. You can find this information in Medicare's Local Coverage Determination 
(LCD): Drug Testing (L34645). 
 
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.