Description

Drug testing is laboratory analysis which aids in the detection of prescription, recreational or illicit substances in an individual. Drug testing is performed for a number of reasons including, but may not be limited to: evaluation of therapeutic compliance, evaluation for drug aberrant behavior such as abuse or diversion, to evaluate for child or elder abuse or based on state mandate requirements. Drug testing can include analysis for most drugs, chemicals or plant products.

Although drug analysis may be performed on a variety of sample types (blood, saliva, sweat, hair and urine), urine drug testing (UDT) is the most commonly utilized. UDT is widely available and has a longer period of potential detection. It is generally the least invasive sample type and least expensive method for drug detection and monitoring. UDT may enhance compliance in an individual prescribed medications such as controlled substances, as well as allow for detection of unexpected prescription, nonprescription or illicit substances. (Refer to Coverage Limitations section)

Types of drug testing:

• Qualitative/Presumptive/Screening – An initial test, commonly performed utilizing qualitative analysis on urine. Qualitative analysis is used to identify the presence or absence of one or more drugs or drug classes.
• Quantitative/Definitive/Confirmatory – A follow-up test performed on a separate portion of the original specimen, utilizing quantitative analysis to validate the identity and quantity of a specific drug or drug metabolite (performed on the same urine specimen to confirm a positive result following qualitative testing).

Validity testing is a urine immunoassay that allows for a basic determination of potential urine sample tampering (eg, dilution, substituted specimen, etc.). Validity testing takes into consideration quality control measures including, but not limited to, the following: creatinine, pH, temperature and specific gravity. (Refer to Coverage Limitations section)

Coverage Determination

Any state mandates for clinical drug testing take precedence over this medical coverage policy.

General Criteria for Drug Testing

Humana members may be eligible under the Plan for drug testing when the following criteria are met:

1. Clinical rationale for all drug testing is clearly documented; AND
2. Drug testing is performed randomly to avoid preparation for the testing; AND
3. Drug testing is tailored to the individual and includes drugs that are prescribed or suspected based on the clinical history; AND

Drug Testing Effective Date: 09/28/2023
Revision Date: 09/28/2023
Review Date: 09/28/2023
Policy Number: HUM-0532-027

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Documentation submitted supports clinical rationale for the drug/drug class testing ordered outside of the clinical presentation history

Criteria for Specific Drug Testing

The following drug testing must meet the above General Criteria for Drug Testing in addition to the individual criteria outlined below for each type of testing.

Qualitative (Presumptive/Screening Testing)

Humana members may be eligible under the Plan for qualitative drug testing in the acute clinical management of an individual when ANY of the following criteria are met:

• Baseline testing prior to initiation of chronic opioid therapy or other drugs with addictive potential (drugs to be tested should be determined upon completion of clinical assessment which includes the risk of potential abuse, diversion using a validated risk assessment, interview or questionnaire when indicated by positive assessment and/or history); OR
• Chronic pain management for an individual on chronic opioid therapy (COT) or other drugs with addictive potential; OR
• Compliance monitoring may be appropriate within 1 to 3 months after baseline screening when noncompliance with treatment regimen is suspected; OR
• Documented potential for drug interactions in an individual with unreliable history, multiple drug ingestion or in a symptomatic individual (eg, documented diagnosis of abnormal behavioral observations, abnormal mental status evaluation, inconsistent history/disclosure and/or abnormal physical evaluation); OR
• Monitoring individual adherence and compliance during active treatment for substance abuse or dependence:
  • An individual may have up to 3 UDTs in a 7 day period when 0 - 90 days of abstinence has been demonstrated; OR
  • An individual may have up to 3 UDTs per month when greater than 90 days abstinence has been demonstrated; OR
• Pediatric/geriatric evaluation of physical or emotional abuse; OR
• Substance abuse, misuse or dependence diagnosis; OR
• Testing for an individual receiving controlled substances or other substances with potential abuse/misuse when specific concerns regarding abuse/misuse are documented during clinical evaluation

Quantitative (Definitive/Confirmation Testing)

Humana members may be eligible under the Plan for quantitative testing when the following criteria are met:

• Testing only of the drug class represented by an inconsistent or unexpected qualitative test, and the medical record demonstrates diagnosis and documentation supporting the medical necessity of the testing by ANY of the following:
  • Qualitative test results are not consistent with expected results based on physical findings; OR
  • Qualitative test results are not consistent with individual’s personal or other reported history; OR
  • Qualitative test results are not consistent with the medications provided by prescription history

For information regarding Direct-to-Consumer Testing, please refer to Code Compendium (Laboratory) Medical Coverage Policy.

Drugs may be classified based on chemical structure, drugs that work in the same way and/or the drugs are used for the same purpose. Humana’s classification of most frequently tested drugs is noted in Table 1 below.

Drug Testing Effective Date: 09/28/2023
Revision Date: 09/28/2023
Review Date: 09/28/2023
Policy Number: HUM-0532-027 Page: 5 of 18

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Table 1: Humana’s Classification of Most Frequently Tested Drugs and Metabolites

• Alcohols
  EtOH, ethylene glycol (ETG), methanol
• Alcohol Biomarkers
  EtG, EtS
• Alkaloids (not otherwise specified)
  Cotinine, LSD, nicotine, psilocybin, scopolamine
• Amphetamines
  Amphetamine, methamphetamine, phentermine, phenylpropanolamine, pseudoephedrine
• Anabolic steroids
  Methyltestosterone, clostebol, danazol, etc.
• Analgesics, non-opioid
  Acetaminophen, diclofenac, ibuprofen, naproxen, ketoprofen
• Antidepressants [serotonergic class (SSRI)]
  Citalopram, duloxetine, fluoxetine, paroxetine, sertraline, trazadone
• Antidepressants (Tricyclic)
  Amitriptyline, desipramine, doxepin, nortriptyline, venlafaxine
• Antidepressants (not otherwise specified)
  Bupropion, desvenlafaxine, selegiline, trazadone, venlafaxine
• Antiepileptics
  Carbamazepine, lamotrigine, phenytoin, primidone, topiramate, valproic acid, zonisamide
• Antipsychotics
  Aripiprazole, clozapine, haloperidol, olanzapine, perphenazine, risperidone, thoridazine, ziprasidone
• Barbiturates
  Amobarbital, butalbital, pentobarbital, phenobarbital, secobarbital, Primidone
• Benzodiazepines
  Alprazolam, chlordiazepoxide, clonazepam, diazepam, lorazepam, temazepam
• Buprenorphine
  Suboxone, Subutex, Sublocade, Sublocade, Bunavail, Zubsolv, Butrans, Probuphine, Belbuca
• Cannabinoids, natural
  Marijuana, Dronabinol carboxy-THC (Marinol), THC, Cannabidiol (CBD; Epidiolex)
• Cannabinoids, synthetic
  Spice varieties
• Cocaine
  Benzoylecgonine, cocaine, ecgonine methyl ester
• Fentanyls
  Acetylfentanyl, alfentanil, fentanyl, norfentanyl, y . v" y y sufentanil, Actiq
• Gabapentin
  Gabapentin
• Heroin metabolite
  6-acetylmorphine (6-MAM), acetylcodeine, diacetylmorphine
• Ketamine and Norketamine
  Ketamine, norketamine
• Methadone
  Methadone, EDDP
• Methylenedioxyamphetamines MDA, MDEA, MDMA (ecstasy)

Drug Testing Effective Date: 09/28/2023
Revision Date: 09/28/2023
Review Date: 09/28/2023
Policy Number: HUM-0532-027 Page: 6 of 18

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Methylphenidate
  Methylphenidate, ritalinic acid
• Opiates
  Codeine, dihydrocodeine, hydrocodone, hydromorphone, morphine
• Opioids-Opiate analogs
  Butorphanol, desomorphine, dextromethorphan, dextrophan, levorphanol, meperidine, naloxone, naltrexone, pentazocine, Kratom, Mitragynine
• Oxycodone
  Oxycodone, oxymorphone, noroxycodone
• Phencyclidine
  Phencyclidine (PCP)
• Pregabalin
  Pregabalin
• Propoxyphene
  Norpropoxyphene, propoxyphene
• Sedative Hypnotics
  Eszopiclone, zaleplon, zolpidem (non-benzodiazepine)
• Skeletal muscle relaxants
  Baclofen, carisoprodol, cyclobenzaprine, meprobamate, Metaxalone, methocarbamol, orphenadrine, tizanidine
• Stereoisomer (enantiomer) analysis
  d/l isomer analysis
• Stimulants, synthetic
  Bath Salts, cathinone, phenethylamines, salvinorin
• Tapentadol
  Tapentadol
• Tramadol
  Tramadol, Ultram, O-Desmethyltramadol
• Drug(s) not otherwise classified
  Miscellaneous

Coverage Limitations

Qualitative (Screening/Presumptive) Testing Humana members may NOT be eligible under the Plan for drug testing for any indications other than those listed above including, but may not be limited to, the following:

• Greater than 1 qualitative test when performed on the same date of service by one or more providers; OR
• Routine, nonspecific standing orders for panel testing; OR
• Routine testing for confirmation of negative qualitative results; OR
• Testing for employment purposes (eg, as a prerequisite for a job or continuation of employment); OR

Drug Testing Effective Date: 09/28/2023
Revision Date: 09/28/2023
Review Date: 09/28/2023
Policy Number: HUM-0532-027 Page: 7 of 18

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Quantitative (Confirmatory) Testing Humana members may NOT be eligible under the Plan for drug testing for any indications other than those listed above including, but may not be limited to, the following:

• Routine, nonspecific standing orders for panel testing; OR
• Specimen validity testing is a mandatory quality control which is an integral part of the collection process and not separately reimbursable; OR
• Testing for employment purposes (eg, as a prerequisite for a job or continuation of employment); OR
• Testing for forensic or medico-legal purposes (eg, court-ordered drug screening); OR
• Testing for more than 7 drug classes (eg, CareView360 [0328U]); OR
• Testing for sociologic determinants (eg, housing); OR
• Testing from multiple source specimens on same date of service; OR

Drug Testing Effective Date: 09/28/2023
Revision Date: 09/28/2023
Review Date: 09/28/2023
Policy Number: HUM-0532-027 Page: 8 of 18

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled.

Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Testing using hair analysis; OR
• Testing without documentation of unexpected or inconsistent qualitative testing

All other indications are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for drug testing for general population screening. This is considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Additional information about drug abuse and drug testing may be found from the following websites:

• Background
  • American Society of Addiction Medicine
  • National Library of Medicine
  • Substance Abuse and Mental Health Services Administration
  • Testing.com

Medical Alternatives

Alternatives to drug testing include, but may not be limited to, the following:

• Complete medical evaluation

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Humana may offer a disease management program for this condition. The member may call the number on his/her identification card to ask about our programs to help manage his/her care.