Harvard Pilgrim HealthCare Medical Policy

Urine Drug Testing

Subject: Urine Drug Testing

Background: Urine drug screening/testing is used in pain management and substance abuse treatment settings to assess and monitor drug misuse and/or abuse. Members in these settings are at risk for abusing or misusing prescribed opioids and/or non-prescribed drugs and should be assessed at the initiation of treatment as well as monitored while they are receiving treatment. Urine drug testing is a widely utilized method for monitoring opioid use in chronic pain individuals. It is used for tracking member compliance and exposing possible drug misuse and abuse. Urine drug testing should not routinely include a panel of all drugs of abuse. The test should be focused on the detection of specific drugs/drug metabolites. The frequency of testing should be at the lowest level to detect the presence of drugs.

Presumptive/Qualitative urine drug testing/screening (UDT) is used to determine the presence or absence of drugs in a urine sample. A positive test result is conveyed when the drug concentration is above the cut-off value. Definitive/Quantitative/Confirmatory urine drug testing (UDT) recognizes medication, illicit substances and metabolites. In contrast to presumptive UDT, definitive testing is performed using a highly sensitive method that specifies particular drugs and drug quantities.

NOTE: All urine drug testing should be performed at an appropriate frequency based on clinical needs. Substance abuse treatment adherence is often best measured through random testing rather than frequent scheduled testing. The preferred method of urine drug testing for a member with a history of poly-substance abuse during the monitoring period is by utilization of a multi-drug screening kit (qualitative analysis by multiplex method for 2-15 drugs or drug classes).

A full panel screen should only be considered for initial testing when appropriate or when the Member’s behavior suggests the use of drugs not identified on the original screening. Medical documentation must support the justification for conducting a full panel screening. Subsequent testing should only be conducted for those substances identified on the Member’s initial profile

Policy and Coverage Criteria:

Presumptive Testing

Harvard Pilgrim Health Care (HPHC) considers presumptive testing as reasonable and medically necessary for individuals with chronic pain when documentation confirms ANY of the following:

• Member is initiating treatment in a pain management or substance abuse program, OR
• Member’s clinical history and evaluation suggests use of non-prescribed medications or illegal substances,
• Member's clinical history and evaluation suggests use of non-prescribed medications or illegal substances, OR
• Member is on chronic opioid therapy and has a history of substance abuse and is at high risk for medication abuse due to psychiatric reasons
• Ongoing monitoring when medical record documentation supports testing is part of an active treatment plan

Harvard Pilgrim Health Care (HPHC) considers presumptive testing as reasonable and medically necessary for individuals with suspected drug overdose when documentation confirms ANY of the following:

• HPHC Medical Policy
• Public Domain

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HPHC policies are based on medical science, and written for the majority of people with a given condition. Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g.,

Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

• Unexplained coma, OR
• Altered mental status in the absence of a clinically defined toxic syndrome or toxidrome, OR
• Severe or unexplained cardiovascular instability (cardiotoxicity), OR
• Unexplained metabolic or respiratory acidosis in the absence of a clinically defined toxic syndrome or toxidrome, OR
• Seizures with an undetermined history, OR
• To provide antagonist to specific drug, OR
• Acute psychiatric events due to stimulant induced psychosis, OR
• Drug use screening for member awaiting organ transplant, OR
• Member under the age of 18 with a sibling with a positive urine drug test
• Possible exposure of the fetus to illicit drugs taken by the mother

Harvard Pilgrim Health Care (HPHC) considers presumptive testing as reasonable and medically necessary for children with history for suspected use of non-prescribed medications or illegal substance.

Definitive Testing

Harvard Pilgrim Health Care (HPHC) considers definitive or confirmatory testing for the treatment planning by the ordering physician (written orders) as reasonable and medically necessary when ANY of the following indications are met:

• A presumptive screen was negative for prescribed medications [Testing should ONLY be ordered for the prescribed drug], OR
• A presumptive screen was positive for a prescription with abuse potential not prescribed to the member, OR
• A presumptive screen was inconclusive or inconsistent, OR
• Qualitative test was positive for an illegal drug

Therapeutic Drug Assays are considered medically necessary when performed to monitor a clinical response to a known, prescribed medication.

Documentation Requirements

All documentation must be maintained in the Member’s medical record and available to Harvard Pilgrim Health Care upon request.

The record must include the identity of the physician or non-physician practitioner responsible for and providing the care of the Member. If requested for review, the submitted medical record should support the use of the selected ICD-CM code(s). The submitted CPT/HCPCS code should describe the service performed. Documentation maintained by the ordering physician/treating physician must indicate the medical necessity for performing a qualitative drug test. All tests must be ordered in writing by the treating provider and all drugs/drug classes to be tested must be indicated in the order. Orders which include statements such as "conduct additional testing as needed or custom profile" will not be accepted by Harvard Pilgrim Health Care. If the provider of the service is other than the ordering/referring physician, that provider must maintain printed copy documentation of the lab results, along with printed copies of the ordering/referring physician’s order for the qualitative drug test. The physician must include the clinical indication/medical necessity in the order for the qualitative drug test.

Exclusions:

Harvard Pilgrim Health Care (HPHC) considers urine drug testing as not medically necessary for all other indications. In addition, HPHC does not cover:

• Specimen validity or adulteration testing

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Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

• Continuous urine drug testing (e.g., Litholink Urine Test)
• Mandated drug testing (e.g., court-ordered, residential monitoring, non-medically necessary testing)
• Employment or job screening testing
• Blanket orders (i.e., identical orders for all members in a clinician's practice without individualized decision making at every visit)

Aspenti Test