Appeal type: unknown
Decision: unknown

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:
A. Although technology has provided the ability to measure many toxins, most toxicological diagnoses and therapeutic decisions are made based on historical or clinical considerations:
1. Laboratory turnaround time can often be longer than the critical intervention time course of an overdose.
2. The cost and support of maintaining the instruments, staff training, and specialized labor involved in some analyses are prohibitive.
3. 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.
B. A qualitative/presumptive drug test may be indicated for a variety of reasons including the following:
1. 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.
2. For monitoring patient compliance during active treatment for substance abuse or dependence.
3. 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.
C. 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:
1. Unexplained coma
2. Unexplained altered mental status in the absence of a clinically defined toxic syndrome or toxidrome
3. Severe or unexplained cardiovascular instability (cardiotoxicity)
4. Unexplained metabolic or respiratory acidosis in the absence of a clinically defined toxic syndrome or toxidrome
5. Testing on neonates suspected of prenatal drug exposure
6. Seizures with an undetermined history
D. 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:
1. For monitoring patient compliance during active treatment for substance abuse or dependence.
2. 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.
3. 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
You can find this rule at Local Coverage Determination (LCD): Drug Testing (L34645) (eff. 5/10/20).
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.