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CurrentArizona Complete HealthPolicy CP.MP.50

Drugs of Abuse: Definitive (Confirmatory) Testing

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Outpatient definitive (quantitative) drug testing coverage criteria for urine and serum drug levels, who may qualify, and tests considered not medically necessary for Arizona Complete Health members under Centene policies.

Policy Summary

PayerArizona Complete Health

PolicyDrugs of Abuse: Definitive (Confirmatory) Testing

Policy CodePolicy CP.MP.50

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization when required and document clinical rationale, including presumptive test results and that requested definitive testing is for ≤ 14 drug/drug classes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≤ 14Maximum drug classes

<6 yrsPA exempt age

G0482/G0483Non-supporting HCPCS

Amp/Coc/Mar/Op/PCPCommon DOA panel

Multiple CPT/HCPCSCoding lists

Coverage Criteria

A. Confirmatory testing after presumptive testing

Covered when ALL of the following are met

A.1: A preliminary/presumptive drug test has been previously performed, unless no reliable test exists (e.g., synthetic cannabinoids)
A.2: Findings from the preliminary/presumptive (qualitative) test are either: a) inconsistent with expected results based on medical history, clinical presentation, or the member's statement after detailed discussion; OR b) consistent with the clinical scenario but drug class–specific assays are needed to identify the precise drug(s)
A.3: Resolving the inconsistency is essential to the ongoing care of the member/enrollee

Policy Summary

PayerArizona Complete Health

PolicyDrugs of Abuse: Definitive (Confirmatory) Testing

Policy CodePolicy CP.MP.50

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization when required and document clinical rationale, including presumptive test results and that requested definitive testing is for ≤ 14 drug/drug classes.

SourceLink

On This Page

A.4: Requested confirmatory/definitive test(s) are for ≤ 14 drugs/drug classes≤ 14

A.5: Tests are limited to the specific drug(s) or number of drug classes for which preliminary analysis yielded unexpected results

B. Expected-positive presumptive testing needing quantitative identification

Covered when ALL of the following are met

B.1: Information regarding the specific substance and/or quantity is desired
B.2: There are established benchmarks for clinical decision making based on the specific substance and/or quantitative levels
B.3: No more than ≤ 14 drugs/drug classes are requested≤ 14
B.4: Tests are limited to the specific drug(s) or number of drug classes for which the presumptive test is expected to be positive

C. Serum therapeutic drug levels

Covered when the following is met

C: Request is for a serum therapeutic drug level in relation to the medical treatment of a disease or condition (e.g., phenobarbital level for seizure management)

III. Over-limit definitive testing

Not medically necessary when

III: Outpatient confirmatory/definitive (quantitative) drug testing of more than 14 drugs/drug classes is requested> 14

Explicitly listed as not medically necessary

Covered indications (summary)

Medically necessary indications (summary from revisions and policy statements):

Medically necessary situations: Includes blanket orders; reflex definitive testing when presumptive testing is performed at point of care; physician standing orders for all patients; billing codes for individual drugs included in a billed panel; presumptive immunoassay testing in a lab when presumptive POC testing has been performed; presumptive screening before definitive testing if presumptive testing not ordered; and IA testing used to confirm a presumptive test result obtained by CLIA‑waived methods.

Extracted from policy summary and revision notes.

Prior authorization

Prior authorization protocols and limits:

PA rules: Testing for children < 6 years of age is exempt from prior authorization; prior authorization requests will be accepted up to 10 business days after specimen collection and reviewed for medical necessity based on the policy criteria.

Procedural/administrative requirement.

The policy explicitly lists a set of administrative and screening uses that are considered not medically necessary. These include testing required as a condition of employment or pre-employment, testing for participation in school or community athletics or extracurricular programs, court-ordered drug screening for medico-legal purposes (unless required by state regulation), screening of asymptomatic patients except where specifically allowed, testing as part of routine physicals or other administrative examinations (e.g., licensing, insurance), same-day multi-source screening across specimen types, blanket orders or routine standing orders for all patients, and specimen validity/adulteration testing. The policy also lists performing presumptive point-of-care testing followed by ordering duplicate presumptive immunoassay testing from a reference laboratory, and using immunoassay (IA) methods to "confirm" CLIA-waived presumptive results, as not medically necessary.

Presumptive testing criteria have been moved to a separate policy (CP.MP.208); this policy focuses on definitive (confirmatory/quantitative) testing. The document emphasizes that presumptive (immunoassay) testing is generally expected before definitive testing except when no reliable presumptive test exists (for example, synthetic cannabinoids). In addition, screening of asymptomatic patients is restricted and is considered not medically necessary unless specific covered indications in this policy apply.

The policy names several explicit not medically necessary situations: outpatient definitive testing that includes >14 drugs/drug classes is considered not medically necessary; numerous administrative and screening uses (employment, school athletics, court-ordered screening except as required by law, routine physicals, blanket orders, reflex definitive tests following POC presumptive testing, and specimen validity/adulteration testing) are also listed as not medically necessary. Coding tables identify specific CPT/HCPCS procedures that do not support coverage for these uses (see coding section), including HCPCS codes G0482 and G0483, which describe multi-class definitive panels of 15–21 and 22+ drug classes respectively, and large-panel CPT codes such as 0054U, 0082U, and 0328U.

For exact billing and coding details, refer to the policy's coding module. The policy lists numerous CPT codes that support coverage criteria (see CPT tables) and identifies HCPCS codes used for definitive drug testing. Pay particular attention to HCPCS descriptors and newer CPT entries when submitting claims. When billing, ensure the selected CPT/HCPCS code matches the number of drug classes and the method claimed (definitive LC/MS or GC/MS versus presumptive immunoassay); coding mismatches with the policy's coverage rules (for example, billing codes describing >14 drug classes) may result in denials.

Covered Indications

Confirmatory/definitive quantitative testing when presumptive testing is inconsistent or when quantitative levels will inform clinical decisions, and serum therapeutic drug levels for treatment monitoring.

Covered uses: Confirmatory/definitive quantitative testing when presumptive testing is inconsistent with the clinical picture or when quantitative levels will inform clinical decisions; and serum therapeutic drug levels for treatment monitoring.≤ 14

See policy sections A, B, and C for detailed criteria.

Definitive testing when clinically indicated (e.g., confirmation following presumptive positive test, physician standing orders, billing for specific drugs included in a panel).

Clinically indicated definitive testing: Definitive testing is covered when clinically indicated, for example to confirm a presumptive positive test, when physician standing orders or reflex testing pathways apply, or when billing for specific drugs included in a billed panel; reflex definitive testing after POC presumptive testing is recognized as a medically necessary indication.≤ 14 when applicable

Presumptive testing criteria relocated to CP.MP.208; reflex/standing-order pathways explicitly recognized.

Frequency Limits

≤ 14 drug/drug classes for definitive testing — Number of drug classes tested

Maximum drug classesDefinitive/confirmatory tests are covered only when the requested test(s) are for ≤ 14 drugs/drug classes.

ScopeApplies to outpatient quantitative definitive drug testing (urine or serum) as described in coverage criteria A and B.

Related limitationRequests exceeding 14 drug/drug classes are considered not medically necessary for outpatient definitive testing.

Presumptive testing limits — referenced limits added in chronic opioid therapy

Presumptive testing in chronic opioid therapyPolicy notes that presumptive drug testing limits were added in chronic opioid therapy to section I.B (details referenced in revision history and moved to CP.MP.208).

Sequencing expectationPresumptive (immunoassay) testing is generally expected before definitive testing unless no reliable presumptive test exists (e.g., synthetic cannabinoids).

Policy relocationPresumptive testing criteria were removed from this policy and relocated to CP.MP.208 (Drugs of Abuse: Presumptive Testing).

Coding

CPT Codes That Support Coverage CriteriaCPTCovered

0011U	Prescription drug monitoring, evaluation of drugs present by LC-MS/MS, using oral fluid, reported as a comparison to an estimated steady-state range, per date of service including all drug compounds and metabolites.
80184	Phenobarbital.
80320	Alcohols.
80321	Alcohol biomarkers; 1 or 2.
80322	Alcohol biomarkers; 3 or more.
80323	Alkaloids, not otherwise specified.
80324	Amphetamines; 1 or 2.
80325	Amphetamines; 3 or 4.
80326	Amphetamines; 5 or more.
80327	Anabolic steroids; 1 or 2.

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CPT Codes That Do Not Support Coverage CriteriaCPTNot Covered

0054U	Prescription drug monitoring, 14 or more classes of drugs and substances, definitive tandem mass spectrometry with chromatography, capillary blood, quantitative report with therapeutic and toxic ranges, including steady-state range for the prescribed dose when detected, per date of service.
0082U	Drug test(s), definitive, 90 or more drugs or substances, definitive chromatography with mass spectrometry, and presumptive, any number of drug classes, by instrument chemistry analyzer (utilizing immunoassay), urine, report of presence or absence of each drug, drug metabolite or substance with description and severity of significant interactions per date of service.
0328U	Drug assay, definitive, 120 or more drugs and metabolites, urine, quantitative liquid chromatography with tandem mass spectrometry (LC-MS/MS), includes specimen validity and algorithmic analysis describing drug or metabolite and presence or absence of risks for a significant patient-adverse event, per date of service.

HCPCS CodesHCPCS

G0480	Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all source(s), includes specimen validity testing, per day, 1 to 7 drug class(es).
G0481	Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day, 8 to 14 drug class(es), including metabolite(s) if performed.
G0659	Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem), excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase), performed without method or drug-specific calibration, without matrix-matched quality control material, or without use of stable isotope or other universally recognized internal standard(s) for each drug, drug metabolite or drug class per specimen; qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes.
G0482	Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15 to 21 drug class(es), including metabolite(s) if performed.
G0483	Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.

Covered CPT Codes (examples added over time)CPTCovered

80367	Code added to coding tables (listed as supporting coverage criteria in prior revisions)
80368	Code added to coding tables
80369	Code added to coding tables
80370	Code added to coding tables; description updated in 2022
80372	Code added to coding tables
80373	Code added to coding tables
82077	2021 CPT added to list of codes that support coverage criteria

HCPCS codes that do not support coverage criteria / noted HCPCSHCPCSNot Covered

G0482	HCPCS described as not supporting coverage criteria (definitive drug test; 15 to 21 drug classes)
G0483	HCPCS described as not supporting coverage criteria (definitive drug test; 22+ drug classes)
0011U	HCPCS added as medically necessary in revision notes
G0659	HCPCS added as medically necessary in revision notes

CPT codes that do not support coverage criteria (examples and changes over time)CPTNot Covered

0143U	CPT listed as not medically necessary (later deleted/removed)
0144U	CPT listed as not medically necessary (later deleted/removed)
0145U	CPT listed as not medically necessary (later deleted/removed)
0146U	CPT listed as not medically necessary (later deleted/removed)
0147U	CPT listed as not medically necessary (later deleted/removed)
0148U	CPT listed as not medically necessary (later deleted/removed)
0149U	CPT listed as not medically necessary (later deleted/removed)
0150U	CPT listed as not medically necessary (later deleted/removed)
0054U	CPT added to list that do not support coverage criteria
0328U	CPT added to list that do not support coverage criteria

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Maximum drug classes for medical necessity — ≤ 14 drugs/drug classes

Medical necessity thresholdMaximum allowed for medical necessity: ≤ 14 drugs/drug classes for definitive/confirmatory testing.

ContextThis threshold is enforced for outpatient confirmatory/definitive quantitative drug testing as described in sections A and B of the policy.

ConsequenceOutpatient definitive testing of more than 14 drugs/drug classes is stated as not medically necessary.

Number of drug classes for G0482/G0483 — G0482: 15 to 21; G0483: 22 or more

G0482 definitionG0482: Definitive drug test(s), per day; 15 to 21 drug class(es), includes metabolite(s) if performed.

G0483 definitionG0483: Definitive drug test(s), per day; 22 or more drug class(es), includes metabolite(s) if performed.

Methodology requirementBoth codes describe use of methods able to identify individual drugs and distinguish structural isomers (e.g., GC/MS, LC/MS) with calibration and quality controls.

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for definitive/outpatient drug testing except for testing performed on children under 6 years of age, which is exempt from prior authorization. Prior authorization requests will be accepted up to 10 business days after specimen collection and will be reviewed for medical necessity based on the policy criteria.

PA requests accepted up to 10 business days post-collection
Children < 6 years — PA exempt

Documentation Required

Documentation for Expected-Positive Presumptive Tests

When a presumptive test is expected to be positive (for example, the member reports recent use), the medical record must document the specific substance(s) and/or quantity the provider is seeking to confirm, and the clinical benchmarks or thresholds that will guide interpretation and subsequent clinical decisions. Requests should be limited to testing for specific drug(s) or drug classes for which the presumptive test is expected to be positive and to ≤ 14 drugs/drug classes.

Document desired specific substance(s) and/or quantity
Document established benchmarks for clinical decision making
Limit requests to ≤ 14 drugs/drug classes

Documentation Required

Reflex Testing

When presumptive testing is performed at point of care, reflex definitive testing may be appropriate if there is a specific physician order recognizing the reflex testing protocol. Reflex definitive testing should only be used when it meets the medical necessity criteria (e.g., to resolve unexpected or clinically important findings) and must be documented in the medical record. Blanket reflex orders without patient-specific clinical justification are not allowed.

Reflex testing allowed only with physician standing order and patient-specific justification
Reflex testing must meet medical necessity criteria and be documented
Blanket/reflex orders without individualized justification are not covered

Ordering Requirements

Documentation Required

Ordering clinician responsibilities and rationale

The ordering clinician must be knowledgeable about the type of testing requested, document the clinical rationale and level of suspicion for drug use, and understand the likelihood of false positives/negatives; presumptive testing is generally expected prior to definitive testing.

Document reason for test and clinical suspicion
Be familiar with test limitations (false positives/negatives)
Order definitive testing only when criteria are met

Note

Reflex definitive testing and standing orders are accepted ordering pathways

Reflex definitive testing after point-of-care presumptive testing and physician standing orders are recognized pathways to medical necessity; the policy references presumptive testing criteria being handled in a separate presumptive testing policy (CP.MP.208).

Not Covered

Summary of scenarios not covered: outpatient definitive testing that includes more than 14 drug/drug classes is not covered. Testing performed for administrative purposes — such as employment or pre-employment screens, school or athletic program requirements, court-ordered or other medico-legal screening (unless state-mandated), routine physicals, licensing/insurance administrative exams, blanket orders, and routine standing orders for all patients — is not covered. Reflex definitive testing ordered solely because a point-of-care presumptive test was performed without a documented clinical indication is not covered, and use of immunoassay methods to 'confirm' CLIA‑waived presumptive test results is also listed as not medically necessary.

Coding-specific not-covered notes: HCPCS codes G0482 (definitive testing for 15–21 drug classes) and G0483 (22 or more drug classes) are identified in the policy as not supporting coverage criteria for outpatient definitive testing. The policy also lists specific CPT codes that do not support coverage (examples include large-panel CPT entries such as 0054U, 0082U, and 0328U); consult the coding tables in this policy for the full and current list.

Definitions

Drugs of Abuse (DOA) definition

DefinitionMedications, substances, chemicals, or plant products known to be misused for recreational or non-prescribed purposes.

ExamplesCommon DOA screening includes amphetamine, cocaine, marijuana, opioids, and phencyclidine; other classes include benzodiazepines, barbiturates, and methamphetamines.

Panel variabilityWhat is included in extended DOA testing can vary by region and epidemiologic trends; no uniform extended panel exists across settings.

Definitive testing definition

Definitive testing descriptionTesting that provides specific identification and/or quantification by methods such as GC/MS or LC/MS/MS, distinguishing from immunoassay-based presumptive testing.

PurposeUsed as confirmatory testing after presumptive screening; offers higher specificity and can identify drugs or metabolites precisely.

Turnaround and useDefinitive methods require specialized lab instrumentation and training, typically take longer, and are generally not used for preliminary point-of-care screening.

Definitive testing definition (alternate)

Isomer distinctionDefinitive testing methods are able to identify individual drugs and distinguish structural isomers (e.g., GC/MS, LC/MS).

Quality standardsDescriptions include use of stable isotope or other internal standards, method- or drug-specific calibration, and matrix-matched quality control material.

Excludes immunoassaysImmunoassays (IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods are excluded from definitive testing without appropriate calibration and standards.

Presumptive testing definition

DefinitionPresumptive testing: immunoassay-based screening tests used prior to definitive testing (e.g., rapid point-of-care immunoassays).

RolePresumptive IA screening is commonly performed as initial testing and generally expected to precede definitive testing unless no reliable IA exists for the drug in question.

Policy relationshipPresumptive testing criteria were relocated to a separate policy (CP.MP.208) and are referenced by this definitive testing policy.

Background

Urine drug testing is commonly used to monitor adherence to controlled substance regimens and to detect misuse. Initial screening typically uses rapid immunoassays (point-of-care tests) because they are fast and practical, but these can produce false positives or negatives. Definitive confirmatory testing uses methods such as GC/MS or LC/MS/MS (often reported as LC-MS/MS) which provide specific identification and/or quantification of drugs and metabolites with higher analytic specificity and are appropriate when results will directly impact major clinical decisions or when presumptive tests are unreliable or inconsistent with the clinical presentation.