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 
 
Group A  Symptomatic patients, Multiple drug ingestion, and/or Patients with unreliable history 
 
A patient who presents in a variety of medical settings with signs or symptoms of substance use toxicity will be 
treated presumptively to stabilize the patient while awaiting presumptive, then definitive testing to determine 
the cause(s) of the presentation. The need for definitive UDT is based upon presumptive test findings, 
responses to medical interventions, and treatment plan1. A presumptive UDT should be performed as part of 
the evaluation and management of a patient who presents in an emergency room or urgent care setting with any 
1 of the following: 
 
Coma; 
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; 
Seizures with an undetermined history; 
To provide antagonist to specific drug. 
The presumptive findings, definitive drug tests ordered, and reasons for the testing must be documented in the 
patients medical record. 
 
Group B - Diagnosis and treatment for substance abuse or dependence 
 
A patient in active treatment for a SUD or monitoring across different phases of recovery may undergo medical 
management for a variety of medical conditions. A physician who is writing prescriptions for medications to treat either the SUD or other conditions may need to know if the patient is taking substances which can interact 
with prescribed medications or taking prescribed medications as expected1. The risk of drug-drug interactions 
is inherent to the patient and may be compounded by prescribed medications. UDT is a medically necessary 
and useful component of chemical dependency diagnosis and treatment. The UDT result influences treatment 
and level of care decisions3.Ordered tests and testing methods (presumptive and/or definitive) must match the 
stage of screening, treatment, or recovery; the documented history; and Diagnostic and Statistical Manual of 
Mental Disorders (DSM V) diagnosis. For patients with no known indicators of risk for SUD, the clinician may 
screen for a broad range of commonly abused drugs using presumptive UDT. For patients with known 
indicators of risk for SUD, the clinician may screen for a broad range of commonly abused drugs using 
definitive UDT. For patients with a diagnosed SUD, the clinician should perform random UDT at random 
intervals to properly monitor the patient3. Testing profiles must be determined by the clinician based on the 
following medical necessity guidance criteria: 
 
Patient history, physical examination, and previous laboratory findings; 
Stage of treatment or recovery; 
Suspected abused substance; 
Substances that may present high risk for additive or synergistic interactions with prescribed medication (e.g., 
benzodiazepines, alcohol). 
The patients medical record must include an appropriate number of UDTs billed over time based on the stage 
of screening, treatment, or recovery9 and the rationale for the drugs/drug classes ordered; and the results must 
be documented in the medical record and used to direct care. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Urine Drug Testing 
(L36029). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.