In outpatient pain management, presumptive (i.e. immunoassay) drug testing may be considered medically necessary for:
Baseline screening before initiating treatment or at the time treatment is initiated, when the following conditions are met:
An adequate clinical assessment of patient history and risk of substance use disorder is performed;
Clinicians have knowledge of test interpretation;
There is a plan in place regarding how to use test findings clinically;
Drug testing is ordered by a clinician during an office visit.
Subsequent monitoring of treatment at a frequency appropriate for the risk level of the individual patient (see Policy Guidelines section).
In outpatient substance use disorder treatment, laboratory, in-office or point-of-care presumptive (i.e. immunoassay) drug testing may be considered medically necessary under the following conditions:
Baseline screening before initiating treatment or at the time treatment is initiated (i.e. induction phase), 1 time per program entry, when the following conditions are met:
An adequate clinical assessment of patient history and risk of substance use disorder is performed;
Clinicians have knowledge of test interpretation;
There is a plan in place regarding how to use test findings clinically;
Drug testing is ordered by a clinician during an office visit.
Stabilization and Maintenance phase –
Using an appropriate test, matrix, and frequency of testing for the risk level of the individual and the substance being used (see Policy Guidelines section)
Documentation in the medical record explains the following (see Policy Guidelines section):
Rationale for the specific test(s) ordered,
Patient’s history of substance use,
How drug testing results will guide medical decision-making.
Definitive (i.e. confirmatory) drug testing, in outpatient pain management or substance use disorder treatment, may be considered medically necessary under the following circumstances:
When immunoassays for the relevant drug(s) are not commercially available
In specific situations for which definitive drug levels are required for clinical decision making (see Policy Guidelines section).
In outpatient pain management and outpatient substance use disorder treatment, drug testing is considered investigational when the above criteria are not met including but not limited to routine presumptive or definitive drug testing or standing orders (eg, testing at every visit, without consideration for specific patient risk factors or without consideration for whether definitive testing is required for clinical decision making) and validity testing when used as a separate evaluation (see Policy Guidelines).
Drug testing in the following settings may be considered medically necessary:
Emergency rooms
Ambulatory surgery
Inpatient services
An abrupt change in mental status (to rule out substance intoxication or delirium)
Drug or alcohol exposure during pregnancy
To rule out a fetal withdrawal syndrome by testing the mother for drug use.
