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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 the patient's medical record must include an appropriate testing frequency based on the stage of screening, treatment, or recovery; the rationale for the drugs/drug classes ordered; and the results must be documented in the medical record and used to direct care. 

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 chronic opioid therapy (COT) are as follows:

COT Baseline Testing: 

Initial presumptive or definitive COT patient testing may include amphetamine/methamphetamine, barbiturates, benzodiazepines, cocaine, methadone, oxycodone, tricyclic antidepressants, tetrahydrocannabinoid, opioids, opiates, heroin, and synthetic/analog or "designer" drugs. 

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.

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice. 

The contractor will consider presumptive UDT testing in excess of 12 per Calendar year not reasonable and necessary.

NOTE: An exception to the above limitation will be made when patients have documented diagnoses consistent with a substance abuse disorder (SUD), for which patients presumptive UDT shall not occur more than 3 times within a seven-day period, based upon the following guidelines for monitoring abstinence. 
For patients with 0 to 30 consecutive days of abstinence, presumptive UDT is expected at a frequency of 1 to 3 presumptive UDT per week. More than 3 presumptive panels in one week is not reasonable and necessary and is not covered by Medicare. For patients with 31 to 90 consecutive days of abstinence, presumptive UDT is expected at a frequency of 1 to 3 UDT per week. More than 3 presumptive UDT in one week is not reasonable and necessary and is not covered by Medicare. 
For patients with more than 90 consecutive days of abstinence, presumptive UDT is expected at a frequency of 1 to 3 UDT in one month. More than 3 physician-directed UDT in one month is not reasonable and necessary and is not covered by Medicare. 
The contractor will only pay for one presumptive UDT test per patient per date of service regardless of the number of billing providers. 
For chronic opioid therapy (COT), the contractor will consider up to 12 definitive tests (i.e., definitive UDT) per Calendar year reasonable and necessary. This would correspond to random testing performed 1-3 times every 3 months for prescribed medications, non-prescribed medications that may pose a safety risk if mixed with prescribed and illicit substances based on patient history, clinical presentation or community usage. You can find this information in Medicare's Local Coverage Determination (LCD): Controlled Substance Monitoring and Drugs of Abuse Testing (L35006).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.