Highmark Commercial Medical Policy - Pennsylvania
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:

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:

*Aberrant behavior is defined by one or more of the following:

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:

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.

Procedure Codes
80305, 80306, 80307


Definitive (i.e., confirmatory, quantitative) drug testing, in outpatient pain management or substance abuse treatment, may be considered medically necessary for the following:

In outpatient pain management and outpatient substance abuse treatment definitive drug testing is considered not medically necessary when the above criteria are not met.

Procedure Codes
80375, 80376, 80377, G0480, G0481, G0482, G0483, G0659


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:

Procedure Codes
80305, 80306, 80307


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.

Procedure Codes
80306, 80307


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.

Procedure Codes
80305


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.

Procedure Codes
80375 , 80376, 80377, G0480, G0481 , G0482, G0483, G0659


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.

Procedure Codes
80305, 80306, 80307, 80375, 80376, 80377, G0480, G0481, G0482, G0483, G0659


The following individual drug tests are considered not medically necessary.

Procedure Codes
80320, 80321, 80322, 80323, 80324, 80325, 80326, 80327, 80328, 80332, 80333, 80334, 80335, 80336, 80337, 80338, 80345, 80346, 80347, 80348, 80349, 80350, 80351, 80352, 80353, 80354, 80355, 80356, 80357, 80358, 80359, 80360, 80361, 80362, 80363, 80364, 80365, 80366, 80367, 80368, 80369, 80370, 80371, 80372, 80373, 80374, 83992


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:

 The following testing is non-covered:


FEP Guidelines

 

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:

  • When prescribing opioids for chronic pain, clinicians should use drug testing before starting opioid therapy and consider drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.

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.

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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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U.S. Department of Health and Human Services
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Room 509F, HHH Building
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1-800-368-1019, 800-537-7697 (TDD)

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