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 Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare & Medicaid 
Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and 
Appeals Guidance Manual, Section 50.12.1.  
 
The rules say that the Medicare contractors could strengthen their program safeguards for ensuring that 
Medicare claims for drug testing services for beneficiaries with substance use disorders comply with Medicare 
requirements. We identified three weaknesses in the established program safeguards for preventing and 
detecting improper payments for drug testing services and promoting provider compliance with Medicare 
requirements. Specifically, the Medicare contractors did not have: 
 
1. clear and consistent requirements or guidance for laboratories to use when determining the number of drug 
classes to bill for definitive drug testing services,  
2. procedures for identifying or limiting the frequency of drug testing services (e.g., the number of drug tests 
performed per year) for each beneficiary across all Medicare jurisdictions, and  3. consistent requirements in their LCDs or any procedures for identifying claims for direct-to-definitive drug 
testing. 
 
You can find this rule in the U.S Department of Health & Human Services, Office of Inspector General - 
Report in Brief from June 2021, Report No. A-09-20-03017 - Opportunities Exist for CMS and Its Medicare 
Contractors To Strengthen Program Safeguards To Prevent and Detect Improper Payments for Drug Testing 
Services. 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare & Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for 
Medicare Services, Chapter I(A). 
 
The rules say that definitive drug testing may be reported with Healthcare Common Procedure Coding System 
(HCPCS) codes G0480-G0483. These codes differ based on the number of drug classes including metabolites 
tested. You can find this rule in the Centers for Medicare & Medicaid Services, Medicare National Correct 
Coding Initiative Policy Manual for Medicare Services, Chapter XII, Section C(11). 
 
The rules say that plans may choose the networks of providers available to enrollees and may require enrollees 
to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in 
the Centers for Medicare & Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed 
Care Manual, Chapter 1, Section 20.2. 
 
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. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on page 37 of the Plan's 2023 
Evidence of Coverage.