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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
The rules say that Non-Covered Services: 
1. Blanket Orders. 
2. Reflex definitive UDT is not reasonable and necessary when presumptive testing is performed at point 
of care because the clinician may have sufficient information to manage the patient. If the clinician is 
not satisfied, he/she must determine the clinical appropriateness of and order specific subsequent 
definitive testing (e.g., the patient admits to using a particular drug, or the IA cut-off is set at such a 
point that is sufficiently low that the physician is satisfied with the presumptive test result). 
3. Routine standing orders for all patients in a physicians practice are not reasonable and necessary. 
4. It is not reasonable and necessary for a physician to perform presumptive POCT and order presumptive 
IA testing from a reference laboratory. In other words, Medicare will only pay for one presumptive test 
result per patient per date of service regardless of the number of billing providers. 
5. It is not reasonable and necessary for a physician to perform presumptive IA testing and order 
presumptive IA testing from a reference laboratory with or without reflex testing. Medicare will only 
pay for one presumptive test result per patient per date of service regardless of the number of billing 
providers. 
6. It is not reasonable and necessary for a reference laboratory to perform and bill IA presumptive UDT 
prior to definitive testing without a specific physicians order for the presumptive testing. 
7. IA testing, regardless of whether it is qualitative or semi-quantitative (numerical), may not be used to 
confirm or definitively identify a presumptive test result obtained by cups, dipsticks, cards, cassettes or other IA testing methods. Definitive UDT provides specific identification or quantification by GC-
MS or LCMS/MS. 
8. Drug testing of two different specimen types from the same patient on the same date of service for the 
same drugs/metabolites/analytes. 
9. UDT for medico-legal or employment purposes or to protect a physician from drug diversion charges. 
10. Specimen validity testing including, but not limited to, pH, specific gravity, oxidants, creatinine. 
You can find these rules in 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. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.