Individuals in pain management and substance abuse treatment programs may misuse prescribed opioids and/or may use non-prescribed drugs. Therefore, individuals in these settings are often assessed before treatment and monitored while they are receiving treatment. Drug screening is one (1) monitoring strategy; it is most often used as part of a multifaceted intervention that includes other components such as individual 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.

Outpatient pain management, presumptive (i.e., qualitative, immunoassay) drug testing may be considered medically necessary when the following are met:

• Baseline screening (induction phase) before initiating treatment or at the time treatment is initiated, when ALL of the following conditions are met:
  • An adequate clinical assessment of individual 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.

Frequency of drug screening to monitor individuals 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 than 120 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 (1) 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 when the following are met:

• Baseline screening (induction phase ) before initiating treatment or at the time treatment is initiated, one (1) time per program entry, when ALL the following are met:
  • Adequate clinical assessment of individual 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 four (4) weeks; or 
• Maintenance phase – targeted presumptive screening once every one (1) to three (3) months. 

Stabilization phase: Some complicated individuals may need frequent drug testing longer than four (4) weeks. (i.e., individuals on an opioid abuse therapy [Suboxone] could require additional drug testing more frequently and longer than four (4) weeks; based on the individual's compliance and drug testing results).

Maintenance phase: More frequent testing may be appropriate for more complicated individuals.

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 when the following are met:

• 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 individual; unexpected negative test (suspected medication diversion); need for quantitative levels to compare with established benchmarks for clinical decision making).

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

Limitations

Presumptive drug testing may be considered medically necessary and will only be allowed one (1) per individual encounter regardless of the number of drug classes tested:

Presumptive drug testing be considered medically necessary when billed in any combination are limited to six (6) tests in a benefit period regardless of the test performed.

Presumptive drug testing may be considered medically necessary and will be limited to 12 tests in a benefit period regardless of the test performed.

Quantity level limits (QLLs) are considered not medically necessary when the frequency guidelines listed above are exceeded.

Definitive drug testing may be considered medically necessary when billed in any combination are allowed one (1) service per date with a limit of 12 tests per benefit period.

QLLs are considered not medically necessary when the frequency guidelines listed above are exceeded.

Drug Testing for Opioid Dependency Limitations 

Drug testing for opioid dependency may be considered medically necessary when billed in any combination are allowed one (1) service per date with a limit of 48 tests per benefit period.

QLLs are considered not medically necessary when the frequency guidelines listed above are exceeded.

Individual drug tests are considered not medically necessary.

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 tests are considered non-covered:

• Non-forensic testing (i.e. job related testing)
• State/legally mandated drug testing