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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 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 and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for Medicare Services, Chapter I(A).  

The rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. Physicians must report services correctly. This manual discusses general coding principles in Chapter I and principles more relevant to other specific groups of HCPCS/CPT codes in the other chapters. There are certain types of improper coding that physicians must avoid. Procedures should be reported with the most comprehensive CPT code that describes the services performed. Physicians must avoid upcoding. A HCPCS/CPT code may be reported only if all services described by that code have been performed.  You can find this guidance in the Medicare Program Integrity Manual, Chapter 3 - Verifying Potential Errors and Taking Corrective Action, Section 3.3.2.1; NCCI Policy Manual, Chapter 1, Introduction, page I-7 and I-8.  

The rules say that definitive urine drug testing (UDT) is reasonable and necessary for the following circumstances:  

1. Identify a specific substance or metabolite that is inadequately detected by a presumptive UDT; 
2. Definitively identify specific drugs in a large family of drugs; 
3. Identify a specific substance or metabolite that is not detected by presumptive UDT such as fentanyl, meperidine, synthetic cannabinoids and other synthetic/analog drugs; 
4. 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); 
5. Identify a negative, or confirm a positive, presumptive UDT result that is inconsistent with a patient's self-report, presentation, medical history, or current prescribed pain medication plan; 
6. Rule out an error as the cause of a presumptive UDT result; 
7. Identify non-prescribed medication or illicit use for ongoing safe prescribing of controlled substances; and 
8. Use in a differential assessment of medication efficacy, side effects, or drug-drug interactions.  

You can find this rule in the Local Coverage Determination (LCD) - Lab: Controlled Substance Monitoring and Drugs of Abuse Testing (L35724) - Effective April 8, 2021.  

The rules say that definitive urine drug testing 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 clinician's rationale for the definitive UDT and the tests ordered must be documented in the patient's medical record. You can find this rule in the Local Coverage Determination (LCD) - Lab: Controlled Substance Monitoring and Drugs of Abuse Testing (L35724) - Effective April 8, 2021.  

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.