Medical Policy. Urine Drug Screening. Policy Number: Policy History

Transcription

1 Policy Number: Policy History Approve Date: 06/13/2016 Effective Date: 12/15/2016 Preauthorization All Plans Benefit plans vary in coverage and some plans may not provide coverage for certain service(s) listed in this policy. Decisions for authorization are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations as well as applicable state and/or federal laws. Please review the benefit plan descriptions for details. Policy Indications of Coverage I. Chronic Pain Programs A. One Baseline screening should be completed before initiating treatment or at the time treatment is initiated, one time per program entry B. Stabilization phase targeted (based upon the drugs member has been prescribed or has reported using) weekly qualitative screening for a maximum of four weeks C. Maintenance phase targeted (based upon the drugs member has been prescribed or has reported using) qualitative screening once every one to three months for a maximum of 15 months D. If after that the member continues with a pain management program testing will be covered one time per calendar year E. Quantitative testing is only covered if there are unexpected negative results from covered qualitative testing basis for classification as unexpected negative test result must be documented in member s clinical records II. Substance Abuse A. Inpatient setting i. Qualitative (immunoassay) Urine Drug Testing/Screening is considered medically necessary as follows: 1. At the time of admission one time per program entry a) Baseline testing should be completed based upon substances member reports he/she is using or is suspect of abusing OR b) If there is suspected history of poly-substance abuse, a multi-drug screening (qualitative analysis by multiplex method for 2-15 drugs) OR c) Full panel screening should only be considered for initial testing when: (i) Member s history or behavior suggests the use of drugs not identified on the original screening 2. Subsequent Urine Drug Testing a) For only those substances identified on the member s initial profile b) Frequency at least every seven days but not more often than every three days c) Quantitative testing is medically necessary when the following is met: (i) Specific situations when quantitative drug levels are required for clinical HT MHS

2 Page 2 decision making AND (ii) Qualitative test was negative for prescribed medication OR (iii) Qualitative test was positive for a prescription drug which was not prescribed OR (iv) Positive for an illegal drug 3. Not medically necessary in either the Inpatient or Residential setting: a) Urine Drug Testing using an all-inclusive, full panel testing b) Testing for the same drug with blood and urine simultaneously is not medically necessary c) Screening for substances not established on the initial targeted screening B. Residential setting i. At time of admission one time per program entry 1. Baseline testing should be completed based upon substances member reports he/she is using or is suspect of abusing OR 2. If there is suspected history of poly-substance abuse, a multi-drug screening (qualitative analysis by multiplex method for 2-15 drugs) OR 3. Full panel screening should only be considered for initial testing when: a) Member s history or behavior suggests the use of drugs not identified on the original screening ii. Subsequent Urine Drug Testing 1. For only those substances identified on the member s initial profile 2. Frequency at least every seven days but not more often than every three days 3. Quantitative testing is medically necessary when the following is met a) Specific situations when quantitative drug levels are required for clinical decision making AND b) Qualitative test was negative for prescribed medication OR c) Qualitative test was positive for a prescription drug which was not prescribed OR d) Positive for an illegal drug 4. Not medically necessary in either the Inpatient or Residential setting: a) Urine Drug Testing using an all-inclusive, full panel testing b) Testing for the same drug with blood and urine simultaneously is not medically necessary c) Screening for substances not established on the initial targeted screening C. Intensive Outpatient programs ii. Quantitative testing is medically necessary when the following is met: iii. Not medically necessary in either the Inpatient or Residential setting: C. Partial Intensive Outpatient programs

3 Page 3 ii. iii. Quantitative testing is medically necessary when the following is met: Not medically necessary in either the Inpatient or Residential setting: C. Outpatient setting ii. iii. Quantitative testing is medically necessary when the following is met: Not medically necessary in either the Inpatient or Residential setting: D. Additional Medically Necessary services i. Urine Drug screening/qualitative testing is medically necessary when any of the following medical conditions and the results will impact the treatment plan: 1. Baseline Altered mental status 2. Medical or psychiatric condition where drug toxicity may be a contributing factor 3. Fetal withdrawal syndrome 4. Possible exposure of fetus to illicit drugs taken by the mother 5. To assess adherence to prescribed medications 6. To evaluate aberrant behavior (e.g. lost prescriptions, repeat requests for early refills, prescriptions from multiple providers or apparent intoxication) E. Not Medically Necessary services i. Urine Drug Testing is not considered medically necessary if provided for reasons that include, but are not limited to the following: 1. Baseline Non medical or third party request including UDT for: a) Employment or pre-employment purposes b) Participation in school or community athletic activities or programs c) Participation in school or community extra-curricular activities d) Court ordered drug testing e) Administrative or social services agency investigations, proceedings or

4 Page 4 monitoring activities f) Testing for parents involved in divorce/child custody cases 2. Testing for residential monitoring 3. Routine specimen for confirmation of specimen integrity F. Additional services not eligible for reimbursement i. At Testing for the same drug with blood and urine simultaneously is not medically necessary for both substance abuse and chronic pain management programs. ii. Routine qualitative/presumptive or quantitative/definitive/confirmatory urine drug testing (e.g. testing at every visit without consideration for specific patient risk factors or without consideration for whether quantitative testing is required for clinical decision making) iii. Quantitative/definitive/confirmatory testing that is discriminately carried out without a iv. positive or unexpected negative result. Quantitative/definitive/confirmatory testing of negative point-of-care results and expected positive results (i.e. know prescribed drugs) G. Investigational services i. In the outpatient pain management and substance abuse treatment, hair drug testing and oral fluid drug testing are considered investigational. There is insufficient evidence to support a conclusion concerning the health outcomes or benefits associated with this procedure. Background Qualitative drug testing/screening testing/presumptive testing (all are defined by CMS as the same thing) testing that determine the presence or absence of drug or drug metabolite in the same. Quantitative drug testing/definitive testing/confirmatory testing identifies the specific drug and quantity of the drug. Stabilization phase: Action stage of treatment following detoxification when the member recognizes that substance abuse causes many of their problems and blocks them from getting things that they want and eventually spends less time on substance abuse per se and turns towards identifying treatment gains that need to be maintained and risks that remain. Positive Result: means that the amount of a substance being tested for is higher or lower than normal. Negative Result: means that the substance or condition being tested for was not found. Inconsistent Result: Term used by some labs when there is an absence of a prescribed drug or the presence of a non-prescribed drug. References The above policy is based on the following references: 1. Christo PJ, Manchikanti L. Ruan X, et al. Urine drug testing in chronic pain. Pain Physician. 2011; 14(2): Owen GT, Burton AW, Schade CM, Passik S. Urine drug testing: current recommendations and best practices. Pain Physician. 2012; 15(3 Suppl):ES119-ES Melanson SE. The utility of immunoassays for urine drug testing. Clin Lab Med. 2012; 32(3): Melanson SE, Ptolemy AS, Wasan AD. Optimizing urine drug testing for monitoring medication compliance in pain management. Pain Med. 2013; 14(12): Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med. 2005; 6(6): American Society of Addiction Medicine. Drug testing: A White Paper of the American Society of Addiction Medicine (ASAM). October 26, Available at:

5 Page 5 7. American Society of Addiction Medicine. National practice guideline for the use of medications in the treatment of addiction involving opioid use Available at: 8. Chou R, Fanciullo GJ, Fine PG, et al.; American Pain Society American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain (2): McMillin GA, Slawson MH, Marin SJ, Johnson-Davis KL. Demystifying analytical approaches for urine drug testing to evaluate medication adherence in chronic pain management. J Pain Palliat Care Pharmacother. 2013; 27(4): PainEDU.org. Opioid risk management. About the SOAPP. Available at: U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. Medication-assisted treatment for opioid addiction in opioid treatment programs. A treatment improvement protocol TIP Available at: Medication-Assisted-Treatment-for-Opioid-Addiction-in-Opioid-Treatment-Programs/SMA U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. Technical Assistance Publication Series 32: Clinical drug testing on primary care Available at: Accessed on January 6, Washington State Agency Medical Directors' Group. Interagency Guideline on Opioid Dosing for Chronic Non-Cancer Pain: An educational aid to improve care and safety with opioid therapy Update. Available at: Accessed on January 6, 2016.