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| Medical Policy: | L-102-016 |
| Topic: | Drug Testing in Pain Management and Substance Abuse Treatment |
| Section: | Laboratory |
| Effective Date: | January 1, 2017 |
| Issue Date: | April 3, 2017 |
| Last Reviewed: | February 2017 |
Patients in pain management and substance abuse treatment programs may misuse prescribed opioids and/or may use non-prescribed drugs. Therefore, patients in these settings are often assessed before treatment and monitored while they are receiving treatment. Drug screening is one monitoring strategy; it is most often used as part of a multifaceted intervention that includes other components such as patient contracts. Presumptive (i.e., qualitative, immunoassay) tests can be performed either in a laboratory or at point of service (POS). Immunoassay tests are based on the principle of competitive binding and use antibodies to detect a particular drug or drug metabolite in a sample. Definitive (i.e., confirmatory, quantitative) are always performed in a laboratory. Gas chromatography/mass spectrometry (GC/MS) is considered to be the “gold standard” for confirmatory testing. This technique involves using GC to separate the analytes in a specimen and MS to identify the specific molecular structures of the drug and its metabolites. |
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
| Policy Position Coverage is subject to the specific terms of the member’s benefit plan. |
Outpatient pain management, presumptive (i.e., qualitative, immunoassay) drug testing may be considered medically necessary for the following:
- Baseline screening (induction phase) before initiating treatment or at the time treatment is initiated, when ALL the following conditions are met:
- An adequate clinical assessment of patient history and risk of substance abuse is performed; and
- Clinicians have knowledge of test interpretation; and
- There is a plan in place regarding how to use test findings clinically.
- Subsequent monitoring of treatment at a frequency appropriate for the risk level of the individual patient.
Frequency of drug screening to monitor patients on opioid therapy for chronic pain is a risk-based approach, as recommended by the Washington State Inter-Agency Guideline:
- Low risk by Opioid Risk Tool (ORT): Up to one (1) per year; or
- Moderate risk by ORT: Up to two (2) per year; or
- High risk or opioid dose greater than120 MED/d: Up to three (3) to four (4) per year; or
- Recent history of aberrant behavior, each visit.
*Aberrant behavior is defined by one or more of the following:
- Multiple lost prescriptions, or
- Multiple requests for early refill, or
- Obtained opioids from multiple provider, or
- Unauthorized dose escalation, or
- Apparent intoxication during previous visits.
Outpatient substance abuse treatment, in-office or point-of-care presumptive (i.e., qualitative, immunoassay) drug testing may be considered medically necessary for the following:
- Baseline screening (induction phase ) before initiating treatment or at the time treatment is initiated, 1 time per program entry, when ALL the following conditions are met:
- An adequate clinical assessment of patient history and risk of substance abuse is performed; and
- Clinicians have knowledge of test interpretation; and
- There is a plan in place regarding how to use test findings clinically.
- Stabilization phase – targeted weekly presumptive screening for a maximum of 4 weeks; or
- Maintenance phase – targeted presumptive screening once every one (1) to three (3) months.
Stabilization phase: Some complicated patients may need frequent drug testing longer than four (4) weeks. (i.e., patients on an opioid abuse therapy [Suboxone] could require additional drug testing more frequently and longer than four (4) weeks; based on the patient's compliance and drug testing results).
Maintenance phase: More frequent testing may be appropriate for more complicated patients.
The use of presumptive drug testing is considered not medically necessary when the above criteria are not met.
Definitive (i.e., confirmatory, quantitative) drug testing, in outpatient pain management or substance abuse treatment, may be considered medically necessary for the following:
- When immunoassays for the relevant drug(s) are not commercially available; or
- In specific situations for which quantitative drug levels are required for clinical decision making (i.e. unexpected positive test inadequately explained by the member; unexpected negative test (suspected medication diversion); need for quantitative levels to compare with established benchmarks for clinical decision making).
In outpatient pain management and outpatient substance abuse treatment definitive drug testing is considered not medically necessary when the above criteria are not met.
Limitations
The following codes for presumptive drug testing will only be allowed one (1) per member encounter regardless of the number of drug classes tested:
The following codes for presumptive drug testing when billed in any combination are limited to six (6) tests within a benefit period regardless of the test performed.
The following code for presumptive drug testing will be limited to 12 tests within a benefit period regardless of the test performed.
Quantity level limits that exceed the frequency guidelines listed above will be considered not medically necessary.
The following codes for definitive drug testing when billed in any combination are allowed one (1) service per date with a limit of 12 tests per benefit period.
Quantity level limits that exceed the frequency guidelines listed above will be considered not medically necessary.
Drug Testing for Opioid Dependency Limitations
The following codes when billed in any combination are allowed one (1) service per date with a limit of 48 tests per benefit period.
Quantity level limits that exceed the frequency guidelines listed above will be considered not medically necessary.
The following individual drug tests are considered not medically necessary.
Documentation in patient’s medical record must contain a history and physical pertinent to the indications of this policy, and be available upon request.
The collection date of the specimen must equal the date of service for the drugs tested.
Benefit year limits do not apply to the following:
- Emergency Room visits
- Inpatient admissions
- Federally regulated testing
The following testing is non-covered:
- Non-forensic testing (i.e. job related testing)
- State/legally mandated drug testing
| FEP Guidelines |
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This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program. |
Refer to medical policy I-92 Naltrexone (Vivitrol®) for Treatment of Alcohol and Opioid Dependence for additional information. Refer to medical policy I-160 Buprenorphine Implant for Treatment of Opioid Dependence for additional information. Refer to medical policy Y-22 Opioid dependence Therapy for additional information. |
| Professional Statements and Societal Positions |
Centers for Disease Control and Prevention (CDC) 2016 guideline for prescribing opioids for chronic pain:
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| Place of Service: Outpatient |
Drug Testing in Pain Management and Substance Abuse Treatment is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
| The policy position applies to all commercial lines of business |
| Denial Statements |
Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
| Links |
- Link to Provider Resource Center for the Medical Policy Update
03/2016, Policy L-102, Drug Testing in Pain Management and in Substance Abuse Denial Reason Changed and Changes made to Limitations.
04/2016, Urine Drug Testing in Pain Management and in Substance Abuse. Addendum to March 2016 Provider Newsletter.
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Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
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