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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 Definitive UDT: Gas Chromatography coupled with Mass Spectrometry (GC-MS) and High 
Performance Liquid Chromatography coupled with Tandem Mass Spectrometry (LC-MS/MS) are complex 
technologies that use the separation capabilities of gaseous or liquid chromatography with the analytical 
capabilities of mass spectrometry. 
 
Both methodologies require the competency of on-site highly trained experts in this technology and 
interpretation of results. While these tests require different sample preparation and analytical runs, they are 
quantitative tests that identify all specific drugs, metabolites, and most illicit substances and report the results 
as absent or present in concentrations of ng/mL. 
 
Quantification should not be used to determine adherence with a specific dosage or time of dose of a pain 
medication or illicit drug for clinical purposes. Rather, the use of quantitative drug data may be important for 
many reasons such as in a differential patient assessment. 
 
For example, when several opioids are present in the urine of a patient prescribed a single opioid, quantification 
may help the clinician decide whether the presence of the other opioids is consistent with metabolism of the 
prescribed opioid, opioid contamination during manufacturing, or if more than one drug within a class is being 
used. 
 
Quantification may also provide information in the setting of illicit drug use. Serial creatinine-corrected 
quantitative values may assist in the differential assessment of ongoing drug use or cessation of drug use with 
continued drug excretion. 
 
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. 
 
Covered Indications for UDT 
 
Group A  Symptomatic patients, multiple drug ingestion or patients with unreliable history. 
 
A patient who presents in a variety of medical settings with signs or symptoms of substance use toxicity will be 
treated presumptively to stabilize the patient while awaiting rapid, then definitive testing to determine the 
cause(s) of the presentation. 
 
The need for definitive UDT is based upon rapid test findings, responses to medical interventions, and 
treatment plan. 
 
A presumptive UDT should be performed as part of the evaluation and management of a patient who presents 
in an urgent care setting with any one of the following: 
 
    Coma 
    Altered mental status in the absence of a clinically defined toxic syndrome or toxidrome 
    Severe or unexplained cardiovascular instability (cardiotoxicity) 
    Unexplained metabolic or respiratory acidosis in the absence of a clinically defined toxic syndrome or 
toxidrome 
    Seizures with an undetermined history 
    To provide antagonist to specific drug 
 
The presumptive findings, definitive drug tests ordered and reasons for the testing must be documented in the 
patient's medical record. 
 
Group B - Diagnosis and treatment for substance abuse or dependence. 
 
A patient in active treatment for substance use disorder (SUD) or monitoring across different phases of 
recovery may undergo medical management for a variety of medical conditions. 
 
A physician who is writing prescriptions for medications to treat either the SUD or other conditions may need 
to know if the patient is taking substances which can interact with prescribed medications or taking prescribed 
medications as expected. 
 
The risk of drug-drug interactions is inherent to the patient, and may be compounded by prescribed medications. 
 
UDT is a medically necessary and useful component of chemical dependency diagnosis and treatment. The 
UDT result influences treatment and level of care decisions. 
 
Ordered tests and testing methods (presumptive or definitive) must match the stage of screening, treatment, or 
recovery; the documented history; and Diagnostic and Statistical Manual of Mental Disorders (DSM V) 
diagnosis. 
 
For patients with no known indicators of risk for SUDs, the clinician may screen for a broad range of 
commonly abused drugs using presumptive UDT. 
 
For patients with known indicators of risk for SUDs, the clinician may screen for a broad range of commonly 
abused drugs using definitive UDT. 
 
For patients with a diagnosed SUD, the clinician should perform random UDT, at random intervals in order to 
properly monitor the patient. Testing profiles must be determined by the clinician based on the following 
medical necessity guidance criteria: 
 
    Patient history, physical examination, and previous laboratory findings 
    Stage of treatment or recovery; 
    Suspected abused substance; 
    Substances that may present high risk for additive or synergistic interactions with prescribed medication 
(e.g., benzodiazepines, alcohol). 
 
The patients medical record must include an appropriate testing frequency based on the stage of screening, 
treatment, or recovery; the rationale for the drugs/drug classes ordered; and the results must be documented in 
the medical record and used to direct care. 
 
Group C - Treatment for patients on chronic opioid therapy (COT). 
 
A physician who is writing prescriptions for medications to treat chronic pain can manage a patient better if the 
physician knows whether the patient is consuming another medication or substance, which could suggest the 
possibility of SUD or lead to drug-drug interactions. Additionally, UDT may help the physician monitor for 
medication adherence, efficacy, side effects, and patient safety in general. 
 
A broad cross section of the general population will develop either cancer pain syndrome or non-cancer pain 
which will require prolonged or chronic opioid therapy for management. The risk of addiction in this 
population is considered equivalent to the risk in the general population. In contrast to the population of 
individuals who have a history of SUD, in the cancer and non-cancer pain population the risk of SUD is 
inherent to the substance(s) to which the patient is exposed. 
 
   1. COT UDT Testing Objectives: 
        Identifies absence of prescribed medication and potential for abuse, misuse, and diversion; 
        Identifies undisclosed substances, such as alcohol, unsanctioned prescription medication, or illicit 
substances; 
        Identifies substances that contribute to adverse events or drug-drug interactions; 
        Provides objectivity to the treatment plan; 
        Reinforces therapeutic compliance with the patient; 
        Provides additional documentation demonstrating compliance with patient evaluation and monitoring; 
        Provides diagnostic information to help assess individual patient response to medications (e.g., 
metabolism, side effects, drug-drug interaction, etc.) over time for ongoing management of prescribed medications. 
   2. Medical Necessity Guidance: 
    Criteria to establish medical necessity for drug testing 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: 
        Patient history, physical examination and previous laboratory findings; 
        Current treatment plan; 
        Prescribed medication(s); and 
        Risk assessment plan. 
 
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.