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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 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 
 
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: 
 
    1. The results of the screen are presumptively positive. 
    2. Results of the screen are negative, and this negative finding is inconsistent with the patient's medical 
history. 
    3. 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.