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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 1. A physician who is writing prescriptions for medications to treat chronic pain can manage a patient better if the physician knows whether the patient is consuming another medication or substance, which could suggest the possibility of SUD or lead to drug-drug interactions. Additionally, UDT may help the physician monitor for medication adherence, diversion, efficacy, side effects, and patient safety in general. COT UDT Testing Objectives: 1. Identifies absence of prescribed medication and potential for abuse, misuse, and diversion; 2. Identifies undisclosed substances, such as alcohol, unsanctioned prescription medication, or illicit substances; 3. Identifies substances that contribute to adverse events or drug-drug interactions; 4. Provides objectivity to the treatment plan; 5. Reinforces therapeutic compliance with the patient; 6. Provides additional documentation demonstrating compliance with patient evaluation and monitoring; 7. Provide diagnostic information to help assess individual patient response to medications (e.g., metabolism, side effects, drug-drug interaction, etc.) over time for ongoing management of prescribed medications.
2. Medical Necessity Guidance: Criteria to establish medical necessity for drug testing must be based on patient-specific elements identified during the clinical assessment, and documented by the clinician in the patient's medical record and minimally include the following elements: Patient history, physical examination and previous laboratory findings; Current treatment plan Prescribed medication(s) Risk assessment plan National pain organizations, physician societies, and the Federation of State Medical Boards recommend a practical approach to definitive UDT for COT. Frequency of testing beyond the baseline presumptive UDT must be based on individual patient needs substantiated by documentation in the patient's medical record. Recommendations for the ordering of presumptive and definitive UDT for patients on COT are as follows: a. COT Baseline Testing: Initial presumptive and/or definitive COT patient testing may include amphetamine/ methamphetamine, barbiturates, benzodiazepines, cocaine, methadone, oxycodone, tricyclic antidepressants, tetrahydrocannabinol, opioids, opiates, heroin, and synthetic/analog or "designer" drugs. b. COT Monitoring Testing: Ongoing testing may be medically reasonable and necessary based on the patient history, clinical assessment, including medication side effects or inefficacy, suspicious behaviors, self-escalation of dose, doctor-shopping, indications/symptoms of illegal drug use, evidence of diversion, or other clinician documented change in affect or behavioral pattern. The frequency of testing must be based on a complete clinical assessment of the individual's risk potential for abuse and diversion using a validated risk assessment interview or questionnaire and should include the patient's response to prescribed medications and the side effects of medications. The clinician should perform random UDT at random intervals, in order to properly monitor a patient. UDT testing does not have to be associated with an office visit. Patients with specific symptoms of medication aberrant behavior or misuse may be tested in accordance with this document's guidance for monitoring patient adherence and compliance during active treatment (less than 90 days) for substance use or dependency. You can find this information in Medicare's Local Coverage Determination (LCD): Lab: Controlled Substance Monitoring and Drugs of Abuse Testing (L35724).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.