Prior Authorization

Prior Authorization may be required. Please validate codes on the Prior Authorization Lookup Tool https://www.highmarkhealthoptions.com/providers/prior-auth-lookup

Procedures

Routine presumptive urine drug testing in substance use disorder treatment (i.e., testing at every visit or without consideration for specific individual risk factors) is considered not medically necessary.

Urine drug testing must be ordered by a licensed practitioner such as a physician or an advanced practitioner (Physician Assistant or Nurse Practitioner) directly involved in care management of the member. Only testing ordered by these providers will be eligible for reimbursement.

Presumptive Tests

Presumptive drug testing may be considered medically necessary and will only be allowed one (1) per date of service, regardless of the number of drug classes tested. Quantity level limits (QLLs) are considered not medically necessary when the frequency guideline above is exceeded.

Presumptive drug testing, when billed in any combination, may be considered medically necessary and will be limited to 24 tests in a benefit period regardless of test performed. QLLs are considered not medically necessary when the frequency guidelines above are exceeded.

Specimen validation testing is inherent to presumptive and confirmatory testing and is considered medically necessary.

Definitive Tests

Definitive testing should be on an individualized basis in accordance with the member’s specific needs. Urine drug testing should be based on an individualized assessment in accordance with the member’s specific needs.

Definitive drug testing may be considered medically necessary under ANY ONE of the following conditions:

• When performed as a reflex by a Clinical Laboratory Improvement Amendments (CLIA) certified laboratory after a positive presumptive test when ANY ONE of the following are met:
  
  • To verify a presumptive positive urine drug test before reporting the presumptive finding to the ordering clinician and without an additional order from the clinician; or
  • In specific situations for which definitive testing is required for clinical decision making and would significantly change a treatment plan (e.g., to distinguish drug supplementation from products of minor metabolic pathways; to help identify individuals diverting medications); or
  • To identify non-prescribed medication or illicit substance use so as to allow safe prescribing of controlled substances in a member without documented or known substance use disorder, where the clinician has documented concerns related to safety risks that may arise due to failure to identify non-prescribed medications or illicit substances.
• When presumptive drug tests are not available for the drug(s) for which there is a suspicion of abuse or misuse, and ALL of the following criteria are met:
  • The clinical presentation of the individual being tested supports the need for the specific drug testing being requested; and
    
  • Results of testing will impact treatment; and
  • Testing is performed in a CLIA certified laboratory.

Definitive and presumptive drug testing is considered not medically necessary when the above criteria are not met.

Definitive drug testing specifically is considered not medically necessary if utilized to identify an adulterant or contaminant that is not an addictive substance unless that substance has a known medically established antidote that reverses its clinical effect.

Definitive drug testing, when billed in combination, may be considered medically necessary and will be allowed one (1) service per date with a limit of 24 tests per benefit period. QLLs are considered not medically necessary when the frequency guidelines listed above are exceeded.

PROCEDURE NONCOVERED

The following tests are considered noncovered:

• Nonforensic testing (i.e., job related testing)
• Generic standing orders or reflex testing that are applied in all cases to all members

Individual drug tests are not considered medically necessary.

The following drug tests are considered experimental/investigational, and therefore, noncovered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature:

• Hair drug testing; and
• Oral fluid drug testing; and
• Meconium drug testing

EXCEPTIONS

Benefit year limits do not apply to the following:

• Emergency room visits
• Inpatient admissions
• Federally regulated testing

REIMBURSEMENT

Participating facilities will be reimbursed per their Highmark Health Options contract.

Highmark Health Options shall consider for reimbursement one (1) unit for CPT codes 80305-80307 and one (1) unit of HCPCS code G0480 or G0659 per member, per date of service, subject to the limitations noted above. HCPCS codes G0481, G0482 and G0483 are not eligible for reimbursement. Highmark Health Options shall not reimburse for more than one (1) unit of presumptive testing, or more than one (1) unit of definitive testing performed on the same date of service, assuming the medical necessity criteria outlined in the above paragraphs are met.

CPT codes 80320–80377 shall be denied, advising the provider to bill with the appropriate HCPCS code, as provided above.

Additional units will be considered for reimbursement upon receipt of the following documentation:

• •           Signed requisition form from the ordering provider. The requisition form must include:
• o          A complete list of the drug class(es) being tested
• o          Both the identity of the member and the provider
• o          The provider credentials including the NPI number and a legible signature
• o          The date and time the sample was collected and/or received at the laboratory
• o          Primary diagnosis and/or appropriate ICD-10 code (2)
• •           Pertinent medical records (History and Physical with assessment and plan)

Post-Payment Audit Statement

The medical record should include documentation that reflects the medical necessity criteria and is subject to audit by Highmark Health Options at any time pursuant to the terms of your provider agreement.

Place of Service

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Drug testing 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.