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. 
 
Presumptive (Qualitative) Drug Testing (hereafter called "presumptive" UDT) 
 
    -Used when medically necessary to determine the presence or absence of drugs or drug classes in a urine 
sample; 
    -Results expressed as negative or positive or as a numerical result; 
    -Includes competitive immunoassays (IA) and thin layer chromatography. 
 
Definitive (Quantitative) Confirmation (hereafter called definitive UDT) 
 
    -Used when medically necessary to identify specific medications, illicit substances and metabolites; Reports 
the results of drugs absent or present in concentrations of ng/ml; 
    -Limited to GC-MS and LC-MS/MS testing methods only. 
 
Presumptive UDT testing is limited for the following reasons: 
 
    -Primarily screens for drug classes rather than specific drugs, and therefore, the practitioner may not be able 
to determine if a different drug within the same class is causing the positive result; 
    -Produces erroneous results due to cross-reactivity with other compounds or does not detect all drugs within 
a drug class; 
    -Given that not all prescription medications or synthetic/analog drugs are detectable or have assays available, 
it is unclear as to whether other drugs are present when some tests are reported as positive; 
    -Cut-off may be too high to detect presence of a drug. This information could cause a practitioner to make a 
wrong assumption or clinical decision. 
 
Definitive UDT is reasonable and necessary in order to:  
    -Identify a specific substance or metabolite that is inadequately detected by a presumptive UDT; 
    -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 (e.g., 
discontinuation of THC use according to a treatment plan); 
    -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. 
The clinicians rationale for the definitive UDT and the tests ordered must be documented in the patients 
medical record You can find this rule in the 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.