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CurrentBlue Cross Blue Shield of VermontPolicy 2.04.VT98

Drug Testing in Pain Management and Substance Use Disorder

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Coverage of qualitative/presumptive and quantitative/definitive urine drug testing for outpatient pain management, substance use disorder treatment, and specified acute-care and pregnancy-related settings, including services that are not medically necessary, investigational, or excluded.

Policy Summary

PayerBlue Cross Blue Shield of Vermont

PolicyDrug Testing in Pain Management and Substance Use Disorder

Policy CodePolicy 2.04.VT98

Change TypeAdministrative and reference updates

Effective DateNovember 1, 2026

Last ReviewJul 1, 2026

Next Review DateJuly 1, 2027

Key ActionVerify the member's benefits, applicable exclusions, and prior approval requirements before providing the service.

SourceLink

POLICY UPDATE CHANGES

The policy review included minor grammatical edits and updated references without changing the policy statement or intent.

50 unitsCombined testing limit per plan year

1 unitApplicable testing limit per date of service

4 weeksStabilization screening duration

Every 1–3 monthsMaintenance screening frequency

InvestigationalHair and oral fluid testing

Medical Necessity and Coverage Criteria

Outpatient pain management baseline screening

Covered when all of the following baseline conditions are met:

Baseline outpatient pain-management screening

Required conditions
- An adequate clinical assessment of the patient's history and risk of substance use disorder is performed; clinicians have knowledge of test interpretation; a plan is in place for using test findings clinically; and drug testing is ordered by a clinician during an office visit.

Outpatient pain management subsequent monitoring

Covered when medically appropriate for the individual patient's risk level:

Subsequent monitoring

Qualitative/presumptive urine drug testing is medically necessary for ongoing treatment monitoring at a frequency appropriate to the individual patient's risk level.

Policy Summary

PayerBlue Cross Blue Shield of Vermont

PolicyDrug Testing in Pain Management and Substance Use Disorder

Policy CodePolicy 2.04.VT98

Change TypeAdministrative and reference updates

Effective DateNovember 1, 2026

Last ReviewJul 1, 2026

Next Review DateJuly 1, 2027

Key ActionVerify the member's benefits, applicable exclusions, and prior approval requirements before providing the service.

SourceLink

On This Page

Frequency must be appropriate to the individual patient's risk level

The policy does not establish one universal outpatient pain-management monitoring frequency.

Substance use disorder treatment phases

Covered when baseline conditions are met and testing corresponds to the treatment phase:

Baseline or induction phase: Laboratory, in-office, or point-of-care qualitative/presumptive urine drug testing may be medically necessary before initiating substance use disorder treatment or at treatment initiation.One time per program entry

An adequate assessment of history and substance use disorder risk, clinician knowledge of test interpretation, a clinical plan for using results, and an order by a clinician during an office visit are required.

Stabilization phase: Targeted weekly qualitative screening may be medically necessary during stabilization.Maximum of 4 weeks

Maintenance phase: Targeted qualitative screening may be medically necessary during maintenance treatment.Once every 1 to 3 months

Random program testing: Random drug testing may be medically necessary as referenced by federal treatment guidelines.At least 8 random tests per year

Quantitative or definitive urine testing

Covered when a specific clinical indication for confirmation is documented:

Definitive urine testing indications

An immunoassay for the relevant drug is not commercially available.
Quantitative drug levels are required for clinical decision making, including comparison with established treatment benchmarks.
An unexpected positive result occurs, including a substance that was not prescribed or a presumptive result inconsistent with the patient's history and physical examination.
An expected positive result is unexpectedly negative, including suspected medication diversion.
A specific substance requires confirmation.

Other medically necessary settings

Testing in the following settings may be medically necessary:

Acute-care and pregnancy-related settings

Emergency-room services.
Ambulatory surgery.
Inpatient services.
An abrupt change in mental status, to rule out substance intoxication or delirium.
Drug or alcohol exposure during pregnancy.
Testing the mother for drug use to rule out fetal withdrawal syndrome.

Presumptive and definitive drug testing

Applicable codes are considered medically necessary when the applicable policy criteria are met and the stated utilization limits are observed:

Conditional medical necessity

The applicable medical-necessity criteria in the policy are met.
The applicable presumptive and definitive drug-testing codes are billed at no more than one unit per date of service.≤ 1 unit per date of service
Combined presumptive and definitive drug-testing units do not exceed the plan-year limit.≤ 50 combined units per plan year

Therapeutic drug quantitation

Code 80299 is considered medically necessary when applicable criteria have been met:

Applicable policy criteria have been met.
The service is billed within the frequency limit.≤ 1 unit per date of service
The code will suspend for medical review.

Denied, excluded, or investigational services

The following services are denied as Not Medically Necessary, Contract Exclusion, or Investigational:

Denied code categories

Codes designated Not Medically Necessary are denied.
Codes designated Contract Exclusion are denied.
Codes designated Investigational are denied.

Testing ordered by or for courts, schools, the military, employers, or other third parties is a benefit exclusion and is not covered. This also applies when testing is ordered solely to satisfy a third party’s requirements.

In outpatient pain management and substance use disorder treatment, hair drug testing and oral fluid drug testing are considered investigational and are not covered as medically necessary services.

Coverage remains subject to the member’s applicable contract and benefit plan. Specific exclusions or limitations may apply, and member contract or employer benefit-plan language takes precedence over this medical policy when the provisions conflict.

Drug-testing services designated as Contract Exclusion are denied, regardless of whether the service might otherwise meet medical-policy criteria.

Routine qualitative/presumptive, quantitative/definitive, or confirmatory urine testing is not medically necessary when policy criteria are not met. This includes testing at every visit without consideration of patient-specific risk factors or whether definitive testing is needed for clinical decision making.

Routine qualitative/presumptive, quantitative/definitive, or confirmatory urine testing beyond 50 combined units per plan year is considered not medically necessary.

Testing is not medically necessary when tests are unbundled from a multi-test kit; definitive testing replaces presumptive screening except when allowed by the policy; or definitive testing is routinely added without an individualized clinical indication. This also includes custom profiles, standing or population-based orders, indiscriminate follow-up testing, testing of negative point-of-care results, and testing of expected positive results for known prescribed drugs.

CPT codes 0148U, 0149U, and 0150U are designated Not Medically Necessary.

Covered, Restricted, and Excluded Codes

Presumptive / Screening / Qualitative Drug Testing CodesCPTCovered

80305	Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; capable of being read by direct optical observation only (e.g., utilizing immunoassay [e.g., dipsticks, cups, cards, or cartridges]), includes sample validation when performed, per date of service.
80306	Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; read by instrument assisted direct optical observation (e.g., utilizing immunoassay [e.g., dipsticks, cups, cards, or cartridges]), includes sample validation when performed, per date of service.

Definitive / Confirmatory / Quantitative Drug Testing CodesHCPCSCovered

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.
G0480	Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers, including but not limited to GC/MS and LC/MS, excluding immunoassays and enzymatic methods; qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed.
G0482	Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers, including but not limited to GC/MS and LC/MS, excluding immunoassays and enzymatic methods; qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed.

Additional Medically Necessary CodeCPTCovered

80299

Quantitation of therapeutic drug, not elsewhere specified.

Presumptive drug testing—direct optical observationCPT

80305

Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; capable of being read by direct optical observation only (e.g., utilizing immunoassay [e.g., dipsticks, cups, cards, or cartridges]), includes sample validation when performed, per date of service.

Presumptive drug testing—instrument-assisted direct optical observationCPT

80306

Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; read by instrument-assisted direct optical observation, including immunoassay devices such as dipsticks, cups, cards, or cartridges; includes sample validation when performed, per date of service.

Presumptive drug testing—instrument chemistry analyzers, chromatography, and mass spectrometryCPT

80307

Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers using immunoassay, chromatography, and mass spectrometry, with or without chromatography; includes sample validation when performed, per date of service.

Presumptive drug testingCPT

80307

Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (e.g., utilizing immunoassay [e.g., EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography (e.g., DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF), includes sample validation when performed, per date of service.

Alcohol testingCPT

80320

Alcohols.

HCPCS Code TableHCPCS

80307	Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers, chromatography, and mass spectrometry either with or without chromatography; includes sample validation when performed, per date of service.
80320	Alcohols
80321	Alcohol biomarkers; 1 or 2
80322	Alcohol biomarkers; 3 or more
80323	Alkaloids, not otherwise specified.

Attachment I and HCPCS Code TableHCPCS

80307	Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers, chromatography, and mass spectrometry either with or without chromatography; includes sample validation when performed, per date of service.
80320	Alcohols
80321	Alcohol biomarkers; 1 or 2
80322	Alcohol biomarkers; 3 or more
80323	Alkaloids, not otherwise specified

Presumptive drug testingHCPCS

80307

Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers, chromatography, and mass spectrometry either with or without chromatography; includes sample validation when performed, per date of service.

Specific analyte testingHCPCS

80320	Alcohols
80321	Alcohol biomarkers; 1 or 2
80322	Alcohol biomarkers; 3 or more.
80323	Alkaloids, not otherwise specified.
80324	Amphetamines; 1 or 2.

HCPCS Code TableHCPCS

80307	Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers, chromatography, and mass spectrometry either with or without chromatography; includes sample validation when performed, per date of service
80320	Alcohols
80321	Alcohol biomarkers; 1 or 2
80322	Alcohol biomarkers; 3 or more
80323	Alkaloids, not otherwise specified
80324	Amphetamines; 1 or 2

HCPCS Code TableHCPCS

80307	Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers, chromatography, and mass spectrometry either with or without chromatography; includes sample validation when performed, per date of service
80320	Alcohols
80321	Alcohol biomarkers; 1 or 2
80322	Alcohol biomarkers; 3 or more
80323	Alkaloids, not otherwise specified

HCPCS Code TableHCPCS

80307	Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers, chromatography, and mass spectrometry either with or without chromatography; includes sample validation when performed, per date of service
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

Presumptive drug testingCPT

80307

Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers.

Analyte-specific drug testingCPT

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

HCPCS Code TableHCPCS

80307	Drug classes, any number of devices or procedures; by instrument chemistry analyzers, chromatography, and mass spectrometry either with or without chromatography; includes sample validation when performed, per date of service
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

Attachment I code table: instrument-based drug testingCPT

80320	Alcohols
80321	Alcohol biomarkers; 1 or 2
80322	Alcohol biomarkers; 3 or more
80323	Alkaloids, not otherwise specified
80324	Amphetamines; 1 or 2

Attachment I code table: definitive drug classes and analytesCPT

80337	Antidepressants, tricyclic and other cyclicals; 6 or more
80338	Antidepressants, not otherwise specified
80339	Antiepileptics, not otherwise specified; 1-3
80340	Antiepileptics, not otherwise specified; 4-6
80341	Antiepileptics, not otherwise specified; 7 or more
80342	Antipsychotics, not otherwise specified; 1-3
80343	Antipsychotics, not otherwise specified; 4-6
80344	Antipsychotics, not otherwise specified; 7 or more
80345	Barbiturates
80346	Benzodiazepines; 1-12

1–10 of 40

1/4

Attachment I code table: drug monitoring and related assaysCPT

83992	Alcohol (ethanol); any specimen except urine and breath, immunoassay and enzymatic methods
0007U	Drug test(s), presumptive, with definitive confirmation of positive results, any number of drug classes, urine, includes specimen verification including DNA authentication in comparison to buccal DNA, per date of service
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
0079U	Comparative DNA analysis using multiple selected single-nucleotide polymorphisms (SNPs), urine and buccal DNA, for specimen identity verification
0093U	Prescription drug monitoring, evaluation of 65 common drugs by LC-MS/MS, urine, each drug reported detected or not detected
0116U	Prescription drug monitoring, enzyme immunoassay of 35 or more drugs confirmed with LC-MS/MS, oral fluid, algorithm results reported as a patient-compliance measurement with risk of drug to drug interactions for prescribed medications
0117U	Pain management, analysis of 11 endogenous analytes by LC-MS/MS, urine, algorithm reported as a pain-index

Definitive drug testing by number of drug classesHCPCS

G0481	Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers; 8-14 drug class(es), including metabolite(s) if performed
G0483	Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers; 22 or more drug class(es), including metabolite(s) if performed

Codes denied as Not Medically Necessary, Contract Exclusion or InvestigationalCPTNot Covered

0054U	Drug test(s), definitive, utilizing drug identification methods to identify individual drugs and distinguish between structural isomers; 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, urine, report of presence or absence of each drug, drug metabolite or substance with description and severity of significant interactions per date of service

Not Medically NecessaryCPTNot Covered

0145U	Drug assay, definitive, 80 or more drugs or metabolites, urine, quantitative LC-MS/MS using multiple reaction monitoring, with drug or metabolite description and sample-validation comments, per date of service
0146U	Drug assay, definitive, drugs or metabolites, urine, by quantitative LC-MS/MS using multiple reaction monitoring, with drug or metabolite description and sample-validation comments, per date of service
0148U	Drug assay, definitive, 100 or more drugs or metabolites, urine, quantitative LC-MS/MS using multiple reaction monitoring, with drug or metabolite description and sample-validation comments, per date of service
0149U	Drug assay, definitive, 60 or more drugs or metabolites, urine, quantitative LC-MS/MS using multiple reaction monitoring, with drug or metabolite description and sample-validation comments, per date of service
0150U	Drug assay, presumptive, 30 or more drugs or metabolites, urine, liquid chromatography with tandem mass spectrometry using multiple reaction monitoring

InvestigationalHCPCSExperimental

0227U	Drug assay, presumptive, 30 or more drugs or metabolites, urine, LC-MS/MS using multiple reaction monitoring, includes sample validation
P2031	Hair analysis (excluding arsenic)

Combined presumptive and definitive testing

Combined annual limitMore than 50 combined presumptive and definitive urine-testing units per plan year is considered not medically necessary.

Testing includedRoutine qualitative/presumptive, quantitative/definitive, and confirmatory urine testing are included in the combined limit.

ApplicationThe limit applies in outpatient pain management and outpatient substance use disorder treatment.

Combined presumptive and definitive drug-testing units

Combined plan-year limitDo not exceed 50 units combined per plan year.

Testing categoriesThe limit combines presumptive drug testing and definitive drug testing units.

Medical necessity conditionApplicable policy criteria must be met in addition to observing the unit limit.

Applicable drug-testing codes

Date-of-service limitDo not exceed 1 unit per date of service.

Code scopeThe limit applies to applicable presumptive and definitive drug-testing codes.

Annual limitApplicable services are also limited to 50 combined units per plan year.

G0480 drug classes

CodeG0480

Drug-class range8–14 drug classes.

MetabolitesIncludes metabolites if performed.

G0482 drug classes

CodeG0482

Drug-class range15–21 drug classes.

MetabolitesIncludes metabolites if performed.

80299 frequency

Code80299

Frequency limitDo not exceed 1 unit per date of service.

Medical reviewThe service may suspend for medical review until applicable criteria have been met.

Alcohol biomarkers

Code80321

Biomarker distinctionAlcohol biomarkers; 1 or 2.

Related categoryAlcohol biomarkers of 3 or more are described separately.

Definitive drug testing, G0481

CodeG0481

Drug-class range8–14 drug classes.

MetabolitesIncludes metabolites if performed.

Definitive drug testing, G0483

CodeG0483

Drug-class threshold22 or more drug classes.

MetabolitesIncludes metabolites if performed.

Investigational drug assay, 0082U

Code0082U

Assay scopeDefinitive testing for 90 or more drugs or substances.

StatusInvestigational.

Authorization, Documentation, and Billing Actions

Prior Authorization

Check Prior Approval and Contract Terms

Prior approval may be required for services under this policy. Confirm applicable benefits and obtain authorization before providing services; benefits remain subject to the subscriber contract’s terms, limitations, and conditions.

Incomplete authorization requests may be delayed until missing information is submitted.
Member contract language takes precedence over this medical policy when the two conflict.

Prior Authorization

80299 Requires Medical Review

Bill code 80299 only when applicable medical-necessity criteria are met. The code is limited to one unit per date of service and will suspend for medical review.

Quantitation of therapeutic drug, not elsewhere specified.
Submit documentation supporting medical necessity and the applicable criteria.

Unsupported block type: prior_auth

Documentation Required

Document Assessment and Testing Plan

Document the clinical assessment and testing plan supporting qualitative or presumptive urine testing. The record must show an adequate assessment of patient history and substance-use-disorder risk, clinician knowledge of test interpretation, and a plan for using results clinically.

Testing must be ordered by a clinician during an office visit.
For substance-use-disorder treatment, document the applicable induction, stabilization, maintenance, or federal-guideline testing context.

Documentation Required

Document the Rationale for Definitive Testing

For definitive or confirmatory testing, document the specific drug or substance being confirmed and the clinical reason for testing it. Use individual substance testing rather than a comprehensive confirmatory panel when appropriate.

Examples include an unavailable immunoassay, an unexpected positive, an unexpected negative suggesting diversion, or a need for quantitative levels for clinical decision-making.

Documentation Required

Verify Benefits and Exclusions

Verify the member’s benefits before providing the service, including whether benefits are available and whether a specific exclusion applies.

Contact the applicable health-plan customer service department and check employer-plan documents when required.
Benefits may differ for NEHP/ABNE, FEP, and ASO members.

Prior Authorization

Complete the Authorization Submission

Submit all information required to make the authorization request complete. A decision may be delayed while missing information is obtained.

Use the policy guidelines and medical-necessity documentation to complete the request.

Unsupported block type: documentation

Billing Rule

Follow Coding-Table Instructions

Follow the policy instructions at the beginning of the drug-testing coding tables when selecting and billing codes. Code-specific instructions include medical-necessity criteria and unit limits.

Review the applicable presumptive and definitive/confirmatory testing instructions before billing.
Do not rely on a code description alone when the coding-table instructions impose additional requirements.

Denial Risk

Individualized Risk-Based Justification Required

Urine drug testing may be denied when it is performed without an individualized, risk-based clinical justification. Routine testing is not medically necessary when patient-specific risk factors and the need for testing are not considered.

Examples include testing at every visit without consideration of individual risk or whether quantitative testing is needed for clinical decision-making.
Apply the policy’s patient-specific medical-necessity criteria before ordering testing.

Denial Risk

Avoid Excessive or Non-Individualized Testing

Avoid excessive, bundled, or non-individualized testing. Testing may be denied when it exceeds the plan-year limit, unbundles a multi-test kit, substitutes definitive testing for presumptive screening without justification, or uses routine and non-individualized testing sequences.

More than 50 combined presumptive and definitive units per plan year is not medically necessary.
Do not order custom profiles, “conduct additional testing as needed,” standing orders, or routine population-based testing.
Do not routinely confirm negative point-of-care results, expected positive results, or indiscriminately confirm results without a positive or unexpected negative.

Denial Risk

Hair and Oral Fluid Testing Is Investigational

Hair drug testing and oral fluid drug testing are considered investigational in outpatient pain management and substance-use-disorder treatment.

Do not assume these specimen types meet the policy’s covered urine-testing criteria.

Denial Risk

Third-Party Testing Is Excluded

Testing ordered by or for a third party is excluded from coverage, including testing required by a court, school, military organization, or employer.

Testing performed solely to satisfy a third-party requirement is not covered.

Denial Risk

Audit Noncompliance May Result in Recoupment

Blue Cross Blue Shield of Vermont may audit any provider or facility for compliance with this medical policy. If an audit identifies noncompliance, the plan may recoup all non-compliant payments.

Maintain documentation supporting medical necessity, ordering, coding, and applicable limits.

Note

Check Contract and Employer-Plan Limitations

Coverage varies by member group or individual contract, and not all groups are subject to Vermont legislative mandates. Confirm the applicable contract and employer-plan terms before providing services.

ASO benefits may vary or may not apply.
Employer benefit-plan documents take precedence over medical policy when there is a conflict.

Billing Rule

Observe Frequency and Unit Limits

Apply the drug-testing frequency and unit limits: no more than one unit per date of service and no more than 50 combined presumptive and definitive drug-testing units per plan year.

The 50-unit limit combines Presumptive Drug Testing and Definitive Drug Testing.
The limit applies to the listed applicable codes, including presumptive and definitive testing codes.

Billing Rule

80299 Claims Suspend for Review

Code 80299 is limited to one unit per date of service and will suspend for medical review when billed under the applicable coding-table instructions.

Ensure the claim is supported by the applicable medical-necessity criteria.

Denial Risk

Avoid Excluded or Investigational Codes

Use of excluded or investigational drug-testing codes may result in denial as not medically necessary, a contract exclusion, or investigational. Code 0082U is specifically designated investigational.

Review the code table’s status before billing.
Code 0082U: prescription drug monitoring involving 90 or more drugs or substances; investigational.

Denial Risk

Specified Drug Assays Are Not Medically Necessary

Drug assays billed with codes 0148U, 0149U, or 0150U are designated not medically necessary under the policy and may be denied.

0148U: definitive assay for 100 or more drugs or metabolites.
0149U: definitive assay for 60 or more drugs or metabolites.
0150U: presumptive assay for 30 or more drugs or metabolites.

Denial Risk

Investigational Drug Testing and Hair Analysis

Codes 0082U, 0227U, and P2031 are designated investigational under the drug-testing code table and may be denied.

0082U: definitive testing of 90 or more drugs or substances with presumptive testing.
0227U: presumptive assay for 30 or more drugs or metabolites.
P2031: hair analysis, excluding arsenic.

Policy Background

Drug testing is one component of a broader monitoring strategy for individuals receiving opioid treatment for chronic pain or treatment for substance use disorder. Urine is the most commonly used specimen; presumptive immunoassay screening generally precedes definitive testing. Definitive testing may be appropriate when immunoassay does not adequately detect a specific substance or when an unexpected result requires clinical clarification.

Definitions and Testing Methods

Qualitative/presumptive drug testing

TermQualitative/presumptive drug testing.

Specimen and methodA urine drug test using an immunoassay.

PurposeProvides an initial, qualitative indication of whether selected drugs or drug classes are present.

Quantitative/definitive drug testing

TermQuantitative/definitive drug testing.

PurposeSpecifically identifies a drug or metabolite.

Analytical methodsGenerally uses gas chromatography/mass spectrometry or liquid chromatography tandem mass spectrometry.

Substance use disorder

TermSubstance use disorder.

Clinical definitionA primary, chronic disease involving brain reward, motivation, memory, and related circuitry.

ManifestationPathologic pursuit of reward and/or relief through substance use and other behaviors.

Presumptive drug test

TermPresumptive drug test.

MethodsPerformed by instrument chemistry analyzers, immunoassay, chromatography, and/or mass spectrometry.

Specimen validationIncludes sample validation when performed and is reported per date of service.

Presumptive drug test

TermPresumptive drug test.

Analytical methodsUses instrument chemistry analyzers, chromatography, mass spectrometry, or combinations of these methods.

Coding-table treatmentIncludes sample validation when performed and is reported per date of service.

Presumptive drug testing

DescriptorDrug test(s), presumptive.

Drug classes and proceduresAny number of drug classes and any number of devices or procedures.

MethodsBy instrument chemistry analyzers, chromatography, or mass spectrometry.

Definitive drug testing

TermDefinitive drug testing.

Identification capabilityUses methods capable of identifying individual drugs and distinguishing structural isomers.

MethodsIncludes methods such as GC/MS and LC/MS and excludes immunoassays and enzymatic methods.

Prescription drug monitoring

TermPrescription drug monitoring.

EvaluationEvaluation of drugs present in a specimen.

ReportingResults may be reported as detected or not detected or compared with an estimated steady-state range.

Specimen validity testing

TermSpecimen validity testing.

DefinitionValidation of the submitted specimen.

Relationship to definitive testingIncluded in the described definitive testing services when performed or specified by the code description.

Excluded and Investigational Services

The following services are not covered under the applicable policy provisions: hair drug testing and oral fluid drug testing, which are investigational in outpatient pain management and substance use disorder treatment; testing ordered by or for a third party, including courts, schools, the military, or employers; and services designated as a contract exclusion. Codes specifically identified as investigational include 0082U, 0227U, and P2031; codes 0148U, 0149U, and 0150U are designated not medically necessary.