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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 state that definitive UDT is considered reasonable and necessary when the clinical information 
supplied supports the definitive testing as in: 
 
-Identify a specific substance or metabolite that is inadequately detected by a presumptive UDT screen; 
-Definitively identify specific drugs in a large family of drugs; 
-Identify a specific substance or metabolite that is not detected by presumptive UDT such as fentanyl, 
meperidine, synthetic cannabinoids, and other synthetic/analog drugs; 
-Identify drugs when a definitive concentration of a drug is needed to guide management; 
-Identify a negative, or confirm a positive, presumptive UDT result that is inconsistent with a patients self-
report, presentation, medical history, or current prescribed pain medication plan; 
-Rule out an error as the cause of a presumptive UDT result; 
-Identify non-prescribed medication or illicit use for ongoing safe prescribing of controlled substances; and 
-Use in a differential assessment of medication efficacy, side effects, or drug-drug interactions. 
 
Definitive UDT may be reasonable and necessary based on patient specific indications, including historical use, 
medication response, and clinical assessment, when accurate results are necessary to make clinical decisions. 
To establish that a test is reasonable and necessary, the clinicians rationale for the definitive UDT and the tests 
ordered must be documented in the patients medical record. 
  
Physician-directed definitive profile testing is reasonable and necessary when ordered for a particular patient 
based upon historical use, clinical findings, and community trends. However, the same physician-defined 
profile is not reasonable and necessary for every patient in a physicians practice. Definitive UDT orders 
should be individualized based on clinical history and risk assessment and must be documented in the medical 
record. 
 Criteria to establish medical necessity for UDT must be based on patient-specific elements identified during the 
clinical assessment, and documented by the clinician in the patients medical record and minimally include the 
following elements: 
 
1. Patient history, physical examination, and previous laboratory findings; 
2. Current treatment plan; 
3. Prescribed medication(s); 
4. Risk assessment plan. 
 
National pain organizations, physician societies, and the Federation of State Medical Boards recommend a 
practical management approach to definitive UDT for COT. The number of UDTs billed over time beyond the 
baseline presumptive UDT must be based on individual patient needs substantiated by documentation in the 
patients medical record. 
 
You can find this information in Local Coverage Determination (LCD): Urine Drug Testing (L34645). 
 
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.