Drug Testing Form

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Drug Testing - Medical Policy
Updated Revision Effective: October 1, 2023 Policy Number: UM698POL

Initial Policy Date: 9/10/2019

Line(s) of Business:

FF
SF
Medicare
MedSupp-G
MedSupp-I
Medicaid

Description

Urine Drug testing is a procedure used frequently in the context of medication assisted treatment (MAT) for substance abuse disorders, to monitor the possibility of ongoing illicit uses of substances, as well as to monitor compliance with certain treatments, such as buprenorphine. The purpose of this policy is to describe the criteria used by HNE’s utilization management team to determine medical necessity of such testing.

Policy

I. Criteria for Approval of Urine Drug Testing: Testing beyond 20 screenings must be prior-authorized by HNE’s Behavioral Health (BH) team and meet medical necessity criteria:

A. After the member’s drugs of use or abuse have been added to their profile, drug testing is limited to

1. Specific drugs present on the initial profile, or

2. Those for which the member has described a history of use during the initial and subsequent medical evaluation

   B. Ordering provider must provide request that is legibly signed and dated. Rubber-stamp signature is not acceptable. General criteria include:

3. Drugs to be screened are clearly identified, and

4. The clinical diagnosis that the testing is being requested for, and

5. Drug testing performed randomly to avoid preparation, and

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4. Drug testing is tailored to member and includes drugs that are prescribed for member or drugs suspected based on member’s clinical history.

   C. A qualitative/presumptive drug test may be indicated for a variety of reasons including the following:

5. A symptomatic patient when the history is unreliable, when there has been a suspected multiple- drug ingestion, to determine the cause of delirium or coma, or for the identification of specific drugs that may indicate when antagonists may be used

6. For monitoring patient compliance during active treatment for substance abuse or dependence

7. To monitor for compliance/adherence to the treatment plan or illicit drug use in patients under treatment or seeking treatment for a chronic pain condition. The clinical utility of drug tests in the emergency setting may be limited because patient management decisions are unaffected, since most therapy for drug poisonings is symptom directed and supportive.

8. When there is an unexpected change in clinical presentation of a patient with known substance abuse or dependence

   D. HNE will consider performance of a qualitative/presumptive drug test reasonable and necessary when a patient presents with one or more of the following conditions:

9. For monitoring patient compliance during active treatment for substance use disorder

10. A drug screen is considered medically reasonable and necessary in patients on chronic opioid therapy:

    a. In whom illicit drug use, non-compliance or a significant pre-test probability of non-adherence to the prescribed drug regimen is suspected and documented in the medical record; and/or
    b. In those who are at high risk for medication abuse due to psychiatric issues, who have engaged in aberrant drug-related behaviors, or who have a history of substance abuse

11. HNE will consider performance of a drug test reasonable and necessary in patients with chronic pain to:

    a. Determine the presence of other substances prior to initiating pharmacologic treatment
    b. Detect the presence of illicit drugs
    c. Monitor adherence to the plan of care

    E. HNE considers definitive drug testing to be indicated when:

12. The results of the screen are presumptively positive.

13. Results of the screen are negative which is inconsistent with the patient’s medical history.

14. This test may also be used when the coverage criteria of the policy are met AND there is no presumptive test available, locally and/or commercially, as may be the case for certain synthetic or semi-synthetic opioids.

    II. What is Not Covered

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A. Testing beyond 20 screenings must be prior-authorized and meet medical necessity criteria outlined in this Drug Testing Medical Coverage Policy.

B. Specimen validity testing on the same date of service as presumptive drug testing

C. Reflex testing

D. Testing based on standard or blanket orders

E. Testing not ordered by a clinician during an office visit (examples include: Halfway House, courts, employers or school drug testing). (BCBS of Mass)

Policy Guidelines and Definitions

I. Required Documentation

A. Medical documentation including the patient’s medical history, clinical presentation and illicit drugs that are commonly used

B. Identify and provide medical information of the reason for and type of drugs being tested.

C. When testing for the presence of drugs not on a member’s drug profile, the rationale must be documented.

II. Definitions

Drug screening - A qualitative/presumptive drug screen is used to detect the presence of a drug in the body. A blood or urine sample may be used. However, urine is the best specimen for broad screening, as blood is relatively insensitive for many common drugs, including psychotropic agents, opioids, and stimulants.

Common methods of drug analysis include chromatography, immunoassay, chemical ("spot") tests, and spectrometry.

Urine Drug Testing (UDT) - Provides objective information to assist clinicians in identifying the presence or absence of drugs or drug classes in the body and making treatment decisions. Plays an integral role in effective medical management of opioids.

Presumptive/Qualitative Drug Testing - 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 - Used when medically necessary to identify specific medications, illicit substances and metabolites; reports the results of analytes absent or present typically in concentrations such as ng/ml; definitive methods include but are not limited to GC-MS and LC-MS/MS testing methods only.

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Analytes - A substance whose chemical contents are being identified and measured.

Chromatography - A laboratory technique for the separation of a mixture by passing in a solution or as a vapor through a medium in which the components move at different rate.

Spectrometry - Scientific instrument used to separate and identify ionized molecules in the gas phase based on the ion stability in a carrier buffer gas.

Assay - An investigative procedure in laboratory medicine, pharmacology, environmental biology and molecular biology for qualitatively assessing or quantitatively measuring the presence, amount, or functional activity of a target entity (the analyte).

Adulteration - A major challenge of urine testing that is manipulation of the urine specimen with chemical adulteration to produce a false negative test result. Common household adulterants include bleach, laundry detergents, table salt and toilet bowl cleaners.

Specimen Validity Testing - Urine specimen testing to ensure that it is consistent with normal human urine and has not been adulterated or substituted; may include, but is not limited to, pH, specific gravity, oxidants and creatinine.

Immunoassay (IA) - Ordered by clinicians primarily to identify the presence or absence of drug classes and some specific drugs; biochemical tests that measure the presence above a cutoff level of a substance (drug) with the use of an antibody; read by photometric technology.

Point of Care Testing (POCT) - Used when medically necessary by clinicians caring for the beneficiary for immediate test results for the immediate management of the beneficiary; available when the beneficiary and physician are in the same location; IA test method that primarily identifies drug classes and a few specific drugs;
platform consists of cups, dipsticks, cassettes, or strips; read by the human eye, or read by instrument assisted direct optical observation.

Standing Orders - Test request for a specific patient representing repetitive testing to monitor a condition or disease for a limited number of sequential visits; individualized orders for certain patients for pre-determined tests based on historical use, risk and community trend patient profiles; clinician can alter the standing order.

Blanket Orders - Test request that is not for a specific patient; rather, it is an identical order for all patients in a clinician’s practice without individualized decision making at every visit.

Reflex Testing - Laboratory testing that is performed "reflexively" after initial test results to identify further diagnostic information essential to patient care. This testing is not based on a specific physician's order. Testing performed as a step necessary to complete a physician’s order is not considered reflex testing.

Coding Guidance

Code
Description
Presumptive Drug Testing 80305
Drug test(s), presumptive, any number of drug classes; any number of devices or procedures, (e.g., immunoassay) capable of being read by direct optical observation only (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service.

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80306
Drug test(s), presumptive, any number of drug classes; any number of devices or procedures, (e.g., immunoassay) read by instrument-assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges, includes sample validation when performed, per date of service. 80307
Drug test(s), presumptive, any number of drug classes, qualitative, any number of devices or procedures by instrument chemistry analyzers (e.g., utilizing immunoassay [e.g., EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (e.g., DART, DESI, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service. Definitive Drug Testing G0480 Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 1-7 drug class(es), including metabolite(s) if performed.
G0481 Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 8-14 drug class(es), including metabolite(s) if performed. G0482 Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 15-21 drug class(es), including metabolite(s) if performed. G0483 Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)); qualitative or quantitative, all sources, includes specimen validity testing, per day, 22 or more drug class(es), including metabolite(s) if performed. G0659
Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including but not limited to GC/MS (any type, single, or tandem) and LC/MS (any type, single or tandem), excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase), performed without method or drug-specific calibration, without matrix-matched quality control material, or without use of stable isotope or other universally recognized internal standard(s) for each drug, drug metabolite or drug class per specimen; qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes. 80320 Alcohols 80321 Alcohol biomarkers; 1 or 2 80322 Alcohol biomarkers; 3 or 4 80323 Alkaloids; not otherwise specified 80324 Amphetamines; 1 or 2 80325 Amphetamines; 3 or 4 80326 Amphetamines; 5 or 6 80327 Anabolic steroids; 1 or 2 80328 Anabolic steroids; 3 or more

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CPT® Copyright 2022 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. 80329 Analgesics, non-opioid; 1 or 2 80330 Analgesics, non-opioid; 3-5 80331 Analgesics, non-opioid; 6 or more 80332 Antidepressants, serotonergic class; 1 or 2 80333 Antidepressants, serotonergic; 3-5 80334 Antidepressants, serotonergic; 6 or more 80335 Antidepressants, tricyclic and other cyclicals; 1 or 2 80336 Antidepressants, tricyclic and other cyclicals; 3-5 80337 Antidepressants, tricyclic and other cyclicals; 6 or more 80338 Antidepressants, not otherwise specified 80339 Antiepileptics, not otherwise specified; 1-3 80340 Antiepileptics, not otherwise specified; 4-6 80341 Antiepileptics, not otherwise specified; not otherwise specified; 7 or more 80342 Antipsychotics, not otherwise specified; 1-3 80343 Antipsychotics, not otherwise specified; 4-6 80344 Antipsychotics, not otherwise specified; 7 or more 80345 Barbiturates 80346 Benzodiazepines; 1-12 80347 Benzodiazepines; 13 or more 80348 Buprenorphine 80349 Cannabinoids, natural 80350 Cannabinoids, synthetic; 1-3 80351 Cannabinoids, synthetic; 4-6 80352 Cannabinoids, synthetic; 7 or more 80353 Cocaine 80354 Fentanyl 80355 Gabapentin, non-blood 80356 Heroin metabolite 80357 Ketamine and norketamine 80358 Methadone 80359 Methylenedioxyamphetamines (MDA, MDEA, MDMA) 80360 Methylphenidate 80361 Opiates; 1 or more 80362 Opioids and opiate analogs; 1 or 2 80363 Opioids and opiate analogs; 3 or 4 80364 Opioids and opiate analogs; 5 or more 80365 Oxycodone 80366 Pregabalin 80367 Propoxyphene 80368 Sedative hypnotics (non-benzodiazepines) 80369 Skeletal muscle relaxants; 1 or 2 80370 Skeletal muscle relaxants; 3 or more 80371 Stimulants, synthetic 80372 Tapentadol 80373 Tramadol 80374 Stereoisomer (enantiomer) analysis, single drug class 83992 Phencyclidine (PC)

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Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

References

Jarvis MD, M, Williams MPH, J, Hurford MD, M, Lindsay PhD, Lincoln MS, D, Giels BS, L, Luongo PhD, P, Safarian BA, T (May/June 2017) Appropriate use of drug testing in clinical addiction medicine. Retrieved August 26, 2022 https://journals.lww.com/journaladdictionmedicine/fulltext/2017/06000/appropriate_use_of_drug_testing_in_c linical.1.aspx

Local Coverage Determination (LCD): Urine Drug Testing (L36037). (n.d.). Retrieved August 26, 2022, from: https://www.cms.gov/medicare-coverage-database/details/lcd- details.aspx?LCDId=36037&ver=46&Date=10/23/2019&DocID=L36037&SearchType=Advanced&bc=KAA AABAAAAAA&.

Sissons, B. (2022, May 17). What to know about urine drug tests. Retrieved August 26, 2022, from:

https://www.medicalnewstoday.com/articles/323378.php.

Drug Testing Resources, Substance Abuse and Mental Health Services Administration (SAMHSA). Retrieved August 26, 2022, from:

https://www.samhsa.gov/workplace/resources/drug-testing

What is Substance Abuse? WebMD. Retrieved on August 26, 2022, from:

https://www.webmd.com/mental-health/addiction/substance-abuse#1

National Institute on Drug Abuse. Retrieved August 26, 2022, from:

https://www.drugabuse.gov/

Additional websites include: (All retrieved August 26, 2022)

http://www.asam.org/

https://www.samhsa.gov/

Hoffman, MD, R, Testing for drugs of abuse (DOAs) (current review Jul 2022). Retrieved August 26, 2022, from: https://www.uptodate.com/contents/testing-for-drugs-of-abuse- doas?search=drug%20testing&source=searchresult&selectedTitle=1~150&usagetype=default&display_rank =1

Dugosh PhD, K, Cacciola PhD, J, Clinical assessment of substance use disorders. Retrieved August 26, 2022, from:

https://www.uptodate.com/contents/clinical-assessment-of-substance-use- disorders?search=drug%20testing&source=searchresult&selectedTitle=5~150&usagetype=default&display_ rank=5

Policy Implementation
Approved by the Medical and Pharmacy Policy Committee

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Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 9/2022 HCPCS Codes reviewed/updated. Policy reviewed by BH team as well.
8/2023 New format, addition of codes

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).
Health New England expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.