HIGHMARK COMMERCIAL MEDICAL POLICY - DELAWARE

 
 
Medical Policy:
L-102-023
Topic:
Drug Testing
Section:
Laboratory
Effective Date:
November 25, 2019
Issued Date:
November 25, 2019
Last Revision Date:
November 2019
Annual Review:
June 2019
 
 

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 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 are usually performed at the 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) tests are always performed in a laboratory and assess multiple drugs at one time. Individual tests are specific to one drug only. Definitive testing is a panel that includes individual drug tests and the associated levels of the specific drugs. Definitive drug testing is more cost effective than individual testing. Gas chromatography/mass spectrometry (GC/MS) is considered to be the gold standard for confirmatory testing

Procedure codes for medically necessary tests within this policy do not require pre-authorization. 

Policy Position

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.

80305

80306

80307

 

 

 

 

 


Specimen validation testing is inherent to presumptive and confirmatory testing and is considered not medically necessary.

82542

82570

83986

84311

84315

 

 

 


Definitive (i.e., confirmatory, quantitative) 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 patients diverting medications); or
    • To identify non-prescribed medication or illicit substance use so as to allow safe prescribing of controlled substances, where the clinician has documented concerns related to safety risks that may arise due to failure to identify non-prescribed medications or illicit substances;  or
  • 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.

80375

80376

80377

G0480

G0481

G0482

G0483

G0659

 

 

 

 

 

 


Limitations

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 guidelines listed above are exceeded.

80305

80306

80307

 

 

 

 


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 listed above are exceeded.

80305

80306

80307

 

 

 

 


Definitive drug testing, when billed in any 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.

80375

80376

80377

G0480

G0481

G0482

G0483

G0659

 

 

 

 

 

 


Individual drug tests are considered not medically necessary.

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

 

 


The following drug tests are considered experimental/investigational, and therefore, non-covered 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

0006U

0007U

0011U

0051U

0054U

0082U

 0116U

0117U

 

 

 

 

 

 


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
Related Policies

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 Guidelines

42 CFR 8.12 - Federal opioid treatment standards 2017
An Opioid Treatment Programs (OTPs) organizational structure and facilities shall be adequate to ensure quality patient care and to meet the requirements of all pertinent Federal, State, and local laws and regulations. At a minimum, each OTP shall formally designate a program sponsor and medical director. The program sponsor shall agree on behalf of the OTP to adhere to all requirements set forth in this part and any regulations regarding the use of opioid agonist treatment medications in the treatment of opioid use disorder which may be promulgated in the future. The medical director shall assume responsibility for administering all medical services performed by the OTP. In addition, the medical director shall be responsible for ensuring that the OTP is in compliance with all applicable Federal, State, and local laws and regulations.

Centers for Disease Control and Prevention (CDC) 2016

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

The guideline is intended to improve communication between clinicians and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder, overdose, and death.

Substance Abuse and Mental Health Service Administration (SAMHSA) 2015 
Medication-Assisted Treatment (MAT) is the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance use disorders. Research shows that a combination of medication and therapy can successfully treat these disorders, and for some people struggling with addiction, MAT can help sustain recovery.

Federal legislation, regulations, and guidelines govern MAT for opioid addiction. SAMHSA’s Division of Pharmacologic Therapies (DPT), part of the SAMHSA Center for Substance Abuse Treatment (CSAT), oversees accreditation standards and certification processes for OTPs. DPT also works with the Drug Enforcement Administration (DEA) and the states to regulate certain medications used in MAT. Additionally, DPT works directly with MAT professionals to improve treatment outcomes and to meet regulatory criteria.

American Society of Addiction Medicine (ASAM) 2017

Appropriate Use of Drug Testing in Clinical Addiction Medicine was published by ASAM in 2017.

  • “As a general principle, drug testing should be scheduled more frequently at the beginning of treatment. The Expert Panel recommends that a patient in early recovery be tested at least weekly. As the patient becomes more stable in recovery, the frequency of drug testing should be decreased, but performed at least on a monthly basis. Individual consideration may be given for less frequent testing if a patient is in stable recovery. If the patient returns to substance use after a period of abstinence, the provider should resume the early recovery testing schedule, possibly in conjunction with an adapted or intensified treatment plan.”


Covered Diagnosis Codes for Procedure code 80305, 80306, 80307, 80375, 80376, 80377, G0480, G0481, G0482, G0483 and G0659

F10.10

F10.120

F10.121

F10.129

F10.150

F10.151

F10.159

F10.180

F10.181

F10.182

F10.188

F10.20

F10.21

F10.220

F10.221

F10.229

F10.230

F10.231

F10.232

F10.239

F10.24

F10.250

F10.251

F10.259

F10.26

F10.27

F10.280

F10.281

F10.282

F10.288

F10.29

F10.920

F10.921

F10.929

F10.94

F10.950

F10.951

F10.959

F10.96

F10.97

F10.980

F10.981

F10.982

F10.988

F10.99

F11.10

F11.11

F11.14

F11.19

F11.20

F11.21

F11.23

F11.24

F11.29

F11.90

F11.93

F11.94

F11.120

F11.121

F11.122

F11.129

F11.150

F11.151

F11.159

F11.181

F11.182

F11.188

F11.220

F11.221

F11.222

F11.229

F11.250

F11.251

F11.259

F11.281

F11.282

F11.288

F11.920

F11.921

F11.922

F11.929

F11.950

F11.951

F11.959

F11.981

F11.982

F11.988

F12.10

F12.120

F12.121

F12.122

F12.129

F12.150

F12.151

F12.159

F12.180

F12.188

F12.19

F12.20

F12.21

F12.220

F12.221

F12.222

F12.229

F12.250

F12.251

F12.259

F12.280

F12.288

F12.29

F12.90

F12.920

F12.921

F12.922

F12.929

F12.950

F12.951

F12.959

F12.980

F12.988

F12.99

F13.10

F13.120

F13.121

F13.129

F13.14

F13.150

F13.151

F13.159

F13.180

F13.181

F13.182

F13.188

F13.19

F13.20

F13.21

F13.220

F13.221

F13.229

F13.230

F13.231

F13.232

F13.239

F13.24

F13.250

F13.251

F13.259

F13.26

F13.27

F13.280

F13.281

F13.282

F13.288

F13.29

F13.90

F13.920

F13.921

F13.929

F13.930

F13.931

F13.950

F13.951

F13.959

F13.96

F13.97

F13.980

F13.981

F13.982

F13.988

F13.99

F14.10

F14.14

F14.19

F14.20

F14.21

F14.23

F14.24

F14.29

F14.90

F14.94

F14.99

F14.120

F14.121

F14.122

F14.129

F14.150

F14.151

F14.159

F14.180

F14.181

F14.182

F14.188

F14.220

F14.221

F14.222

F14.229

F14.250

F14.251

F14.259

F14.280

F14.281

F14.282

F14.288

F14.920

F14.921

F14.922

F14.929

F14.950

F14.951

F14.959

F14.980

F14.981

F14.982

F14.988

F15.10

F15.120

F15.121

F15.122

F15.129

F15.150

F15.151

F15.159

F15.180

F15.181

F15.182

F15.188

F15.19

F15.20

F15.21

F15.220

F15.221

F15.222

F15.229

F15.23

F15.24

F15.250

F15.251

F15.259

F15.280

F15.281

F15.282

F15.288

F15.29

F15.90

F15.920

F15.921

F15.922

F15.929

F15.93

F15.94

F15.950

F15.951

F15.959

F15.980

F15.981

F15.982

F15.988

F15.99

F16.10

F16.14

F16.19

F16.20

F16.21

F16.24

F16.29

F16.90

F16.94

F16.99

F16.120

F16.121

F16.122

F16.129

F16.150

F16.151

F16.159

F16.180

F16.183

F16.188

F16.220

F16.221

F16.229

F16.250

F16.251

F16.259

F16.280

F16.283

F16.288

F16.920

F16.921

F16.929

F16.950

F16.951

F16.959

F16.980

F16.983

F16.988

F18.10

F18.11

F18.120

F18.121

F18.129

F18.14

F18.150

F18.151

F18.159

F18.17

F18.180

F18.188

F18.19

F18.20

F18.21

F18.220

F18.221

F18.229

F18.24

F18.250

F18.251

F18.259

F18.27

F18.280

F18.288

F18.29

F18.90

F18.920

F18.921

F18.929

F18.94

F18.950

F18.951

F18.959

F18.97

F18.99

F19.10

F19.120

F19.121

F19.122

F19.129

F19.14

F19.150

F19.151

F19.159

F19.16

F19.17

F19.180

F19.181

F19.182

F19.188

F19.220

F19.221

F19.222

F19.229

F19.230

F19.231

F19.232

F19.239

F19.24

F19.250

F19.251

F19.259

F19.26

F19.27

F19.280

F19.281

F19.282

F19.288

F19.29

F19.90

F19.920

F19.921

F19.922

F19.929

F19.930

F19.931

F19.932

F19.939

F19.94

F19.950

F19.951

F19.959

F19.96

F19.97

F19.980

F19.981

F19.988

F19.99

F45.42

G89.4

G89.21

G89.22

G89.28

G89.29

O99.320

O99.321

O99.322

O99.323

O99.324

 Z51.81

 Z76.0

 Z79.891

Z79.899

 

 

 

 

 

 


Non-Covered Diagnosis Codes for 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

F10.10

F10.120

F10.121

F10.129

F10.150

F10.151

F10.159

F10.180

F10.181

F10.182

F10.188

F10.20

F10.21

F10.220

F10.221

F10.229

F10.230

F10.231

F10.232

F10.239

F10.24

F10.250

F10.251

F10.259

F10.26

F10.27

F10.280

F10.281

F10.282

F10.288

F10.29

F10.920

F10.921

F10.929

F10.94

F10.950

F10.951

F10.959

F10.96

F10.97

F10.980

F10.981

F10.982

F10.988

F10.99

F11.10

F11.11

F11.14

F11.19

F11.20

F11.21

F11.23

F11.24

F11.29

F11.90

F11.93

F11.94

F11.120

F11.121

F11.122

F11.129

F11.150

F11.151

F11.159

F11.181

F11.182

F11.188

F11.220

F11.221

F11.222

F11.229

F11.250

F11.251

F11.259

F11.281

F11.282

F11.288

F11.920

F11.921

F11.922

F11.929

F11.950

F11.951

F11.959

F11.981

F11.982

F11.988

F12.10

F12.120

F12.121

F12.122

F12.129

F12.150

F12.151

F12.159

F12.180

F12.188

F12.19

F12.20

F12.21

F12.220

F12.221

F12.222

F12.229

F12.250

F12.251

F12.259

F12.280

F12.288

F12.29

F12.90

F12.920

F12.921

F12.922

F12.929

F12.950

F12.951

F12.959

F12.980

F12.988

F12.99

F13.10

F13.120

F13.121

F13.129

F13.14

F13.150

F13.151

F13.159

F13.180

F13.181

F13.182

F13.188

F13.19

F13.20

F13.21

F13.220

F13.221

F13.229

F13.230

F13.231

F13.232

F13.239

F13.24

F13.250

F13.251

F13.259

F13.26

F13.27

F13.280

F13.281

F13.282

F13.288

F13.29

F13.90

F13.920

F13.921

F13.929

F13.930

F13.931

F13.950

F13.951

F13.959

F13.96

F13.97

F13.980

F13.981

F13.982

F13.988

F13.99

F14.10

F14.14

F14.19

F14.20

F14.21

F14.23

F14.24

F14.29

F14.90

F14.94

F14.99

F14.120

F14.121

F14.122

F14.129

F14.150

F14.151

F14.159

F14.180

F14.181

F14.182

F14.188

F14.220

F14.221

F14.222

F14.229

F14.250

F14.251

F14.259

F14.280

F14.281

F14.282

F14.288

F14.920

F14.921

F14.922

F14.929

F14.950

F14.951

F14.959

F14.980

F14.981

F14.982

F14.988

F15.10

F15.120

F15.121

F15.122

F15.129

F15.150

F15.151

F15.159

F15.180

F15.181

F15.182

F15.188

F15.19

F15.20

F15.21

F15.220

F15.221

F15.222

F15.229

F15.23

F15.24

F15.250

F15.251

F15.259

F15.280

F15.281

F15.282

F15.288

F15.29

F15.90

F15.920

F15.921

F15.922

F15.929

F15.93

F15.94

F15.950

F15.951

F15.959

F15.980

F15.981

F15.982

F15.988

F15.99

F16.10

F16.14

F16.19

F16.20

F16.21

F16.24

F16.29

F16.90

F16.94

F16.99

F16.120

F16.121

F16.122

F16.129

F16.150

F16.151

F16.159

F16.180

F16.183

F16.188

F16.220

F16.221

F16.229

F16.250

F16.251

F16.259

F16.280

F16.283

F16.288

F16.920

F16.921

F16.929

F16.950

F16.951

F16.959

F16.980

F16.983

F16.988

F18.10

F18.11

F18.120

F18.121

F18.129

F18.14

F18.150

F18.151

F18.159

F18.17

F18.180

F18.188

F18.19

F18.20

F18.21

F18.220

F18.221

F18.229

F18.24

F18.250

F18.251

F18.259

F18.27

F18.280

F18.288

F18.29

F18.90

F18.920

F18.921

F18.929

F18.94

F18.950

F18.951

F18.959

F18.97

F18.99

F19.10

F19.120

F19.121

F19.122

F19.129

F19.14

F19.150

F19.151

F19.159

F19.16

F19.17

F19.180

F19.181

F19.182

F19.188

F19.220

F19.221

F19.222

F19.229

F19.230

F19.231

F19.232

F19.239

F19.24

F19.250

F19.251

F19.259

F19.26

F19.27

F19.280

F19.281

F19.282

F19.288

F19.29

F19.90

F19.920

F19.921

F19.922

F19.929

F19.930

F19.931

F19.932

F19.939

F19.94

F19.950

F19.951

F19.959

F19.96

F19.97

F19.980

F19.981

F19.988

F19.99

F45.42

G89.4

G89.21

G89.22

G89.28

G89.29

O99.320

O99.321

O99.322

O99.323

O99.324

 Z51.81

 Z76.0

 Z79.891

Z79.899

 

 

 

 

 

 


Place of Service: Inpatient/Outpatient

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


The policy position applies to all commercial lines of business



Links





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 or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

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, and subject to the applicable laws of your state.


Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as: 
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as: 
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator. 

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. 

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: 

U.S. Department of Health and Human Services 
200 Independence Avenue, SW 
Room 509F, HHH Building 
Washington, D.C. 20201 
1-800-368-1019, 800-537-7697 (TDD) 

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. 

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. 




Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.