OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

Modifiedblue cross blue shield - louisianaPolicy AHS - T2015

Prescription Medication and Illicit Drug Testing in the Outpatient Setting

Customize your policy alerts

Sign up for blue cross blue shield - louisiana Policy AHS - T2015 alerts

Get alerted when Policy AHS - T2015 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Coverage criteria for presumptive and definitive outpatient drug testing (primarily urine/oral fluid) for prescription and illicit substances; applies to outpatient clinical toxicology (not forensic or therapeutic drug monitoring) for Blue Cross Blue Shield - Louisiana members.

Policy Summary

Payerblue cross blue shield - louisiana

PolicyPrescription Medication and Illicit Drug Testing in the Outpatient Setting

Policy CodePolicy AHS - T2015

Change TypeMaterial coverage updates and coding revisions (frequency limits, default exclusion, documentation and panel-size limits)

Effective DateAug 1, 2026

Last ReviewAug 1, 2026

Next Review DateN/A

Key ActionTreating physician must specifically request laboratory-based definitive (confirmatory) testing and document the clinical rationale in the medical record.

SourceLink

POLICY UPDATE CHANGES

Added language '(up to 2 per week and 24 per year)' to CC1 and CC2 to limit presumptive and confirmatory testing frequency.

Added new 'General' section and new CC6: 'In all other situations not addressed above, presumptive drug screening and definitive drug testing DO NOT MEET COVERAGE CRITERIA.'

Confirmatory/definitive qualitative or quantitative drug testing coverage clarified to be 'up to seven drug classes' and requires laboratory-based definitive testing specifically requested with documented rationale by treating physician.

Off-cycle coding modification: Added CPT code 0603U and revised CPT code 0517U (removed manufacturer).

2/wk;24/yrfrequency limit (week/year)

≤7 classesmax definitive panel

urine, oral fluidcovered specimen types

specimen validityexcluded tests

08/01/2026last reviewed

Coverage Criteria

Presumptive Drug Screening (Urine)

Presumptive urine drug screening meets coverage when ANY of the following clinical indications apply (up to 2/week and 24/year):

Chronic non-cancer pain assessment and monitoring: Assessment of individuals treated for chronic non-cancer pain when clinical evaluation (history, signs, symptoms) suggests use of non-prescribed medications or illegal substances; includes: prior to initiating chronic opioid therapy to determine exposure to controlled substances or confounding illicit drugs; routine monitoring to verify compliance or identify undisclosed drug abuse; testing at time of visit for individuals with aberrant behaviors (lost prescriptions, early refill requests, multiple providers, unauthorized dose escalation, apparent intoxication).up to 2/week and 24/year

Monitoring frequency after initiation: low risk once/year; moderate risk up to twice/year; high risk up to four times/year; random testing interval and drug selection should be based on documented history, condition, and treatment.

High-risk pregnancy and newborn evaluation: Pregnant individuals at high risk for substance abuse when suspicion exists based on screening questions or PDMP information (documented in the medical record); newborns when there is a history of maternal substance abuse or altered maternal mental status.

Policy Summary

Payerblue cross blue shield - louisiana

PolicyPrescription Medication and Illicit Drug Testing in the Outpatient Setting

Policy CodePolicy AHS - T2015

Change TypeMaterial coverage updates and coding revisions (frequency limits, default exclusion, documentation and panel-size limits)

Effective DateAug 1, 2026

Last ReviewAug 1, 2026

Next Review DateN/A

Key ActionTreating physician must specifically request laboratory-based definitive (confirmatory) testing and document the clinical rationale in the medical record.

SourceLink

On This Page

up to 2/week and 24/year

Testing should follow applicable professional guidance and state law regarding prenatal testing and consent.

Pre-transplant and treatment-program monitoring: Organ transplant candidates with a history of substance abuse to demonstrate abstinence prior to transplant; management and compliance monitoring for individuals in substance abuse treatment (frequency by abstinence duration: 0–90 days: 1–2 tests/week; >90 days: 1–3 tests/month), with baseline testing at initial evaluation.up to 2/week and 24/year

Random testing and documentation of frequency must be in the medical record.

Behavioral health and neurologic contexts: Individuals with suspected or diagnosed mental illness (e.g., anxiety, schizophrenia, major depression, suicidal ideation, substance use disorder), individuals with ADHD/disruptive behavior disorders, cancer patients on opioid medication, and individuals with epilepsy when substance use is in the differential diagnosis.up to 2/week and 24/year

Use clinical judgment and guideline-recommended screening tools to determine need for testing.

Definitive Drug Testing (Laboratory-based)

Definitive/confirmatory laboratory-based drug testing (qualitative or quantitative) meets coverage when ALL of the following are met:

General requirements: The test is laboratory-based definitive testing (e.g., GC-MS, LC-MS/MS), is specifically requested by the treating physician, and the clinical rationale is documented in the patient's medical record.<=7 classes; <=2/week; <=24/year

Coverage limited to panels of up to seven drug classes; frequency limits apply.

Indications for definitive testing: a) Presumptive screen result discordant with the patient's history, clinical presentation, or statement (e.g., negative for prescribed meds, positive for non-prescribed prescription or illegal drug); b) Diagnosing or monitoring substance use disorder when accurate, reliable results are necessary for treatment decisions (frequency by abstinence duration: 0–30 days: ≤1/week; 31–90 days: 1–3/month, max 3/month; >90 days: 1–3 every 3 months, max 3/3 months); c) Monitoring individuals on opioid therapy to ensure adherence and detect non-prescribed opioids; d) When no adequate presumptive test exists or a presumptive test does not detect the specific drug/metabolite; e) To definitively identify specific drugs within a large family; f) When a definitive concentration is needed to guide management.frequency limits as stated; up to 7 classes

Physician documentation required for medical necessity and panel composition.

Not Covered

Not covered situations:

Panels and proprietary assays not covered: Definitive testing for panels larger than seven drug classes DOES NOT MEET COVERAGE CRITERIA; confirmatory or presumptive testing using proprietary platforms (examples cited in policy such as CareView360 and other proprietary/PLA tests) DOES NOT MEET COVERAGE CRITERIA.

See coding table for proprietary test codes; providers should use listed HCPCS/PLA codes when billing where applicable but note exclusion applies to coverage decision.

Specimen validity and identity testing not covered: Specimen validity testing (e.g., urine specific gravity, urine creatinine, pH, urine oxidant level) and genetic identity testing DO NOT MEET COVERAGE CRITERIA.

These specimen validity assays are explicitly excluded.

General default exclusion: In all situations not specifically addressed in the policy, presumptive drug screening and definitive drug testing DO NOT MEET COVERAGE CRITERIA.

New default exclusion (CC6) added; absence of a listed indication is a basis for denial.

Duplicate or blanket routine testing not covered: Blanket or routine standing orders for all patients in a practice and same-day testing of the same drug/metabolite from two different samples (duplicate testing) are not reimbursed and considered not reasonable/necessary.

When both POC presumptive and reference lab presumptive testing on the same specimen are performed, only one will be reimbursed.

Guideline-based baseline and risk-stratified monitoring

Covered when testing follows guideline-based indications and is expected to affect patient management; definitive testing preferred in many scenarios

Baseline and risk-stratified monitoring for controlled substances: Perform baseline urine drug monitoring prior to initiation of opioid therapy and periodic monitoring thereafter with frequency based on risk level: low risk—at least annually (every 6–12 months), moderate risk—every 3–6 months, high risk—every 1–3 months or ≥3 times/year. Additional monitoring may be performed as clinically indicated.risk-stratified frequency

Recommendations referenced from AACC, consensus panels, and CDC; definitive methods preferred for baseline and where decision impact is high.

Definitive/confirmatory testing criteria

Use of confirmatory and definitive testing

When confirmatory/definitive testing is indicated: Use definitive confirmatory testing (e.g., GC-MS, LC-MS/MS) when results will inform major clinical or nonclinical decisions, when specific opioids or metabolites must be identified, when immunoassay results are unexpected or inconsistent with clinical expectations, or when a definitive concentration is required to guide management; limit confirmatory testing to situations expected to affect patient management.

CDC and AACC recommend confirmatory testing for unexpected or decision-driving results; SAMHSA and specialty guidance support definitive methods in OTPs and for problematic results.

Operational requirement for confirmatory testing: Laboratory-based definitive drug testing must be specifically requested by the treating physician and the clinical rationale documented in the medical record for coverage to apply.

Documentation requirement reinforced in policy revision history.

Assay performance and selection

Assay selection considerations

Prefer definitive methods when specificity and sensitivity are required: Definitive (mass spectrometry-based) methods are preferred due to superior sensitivity and specificity; immunoassays have variable cross-reactivity and may miss positives (e.g., ~21% false negatives for opiates in one study) and should be interpreted with knowledge of assay limitations and package inserts.

Clinicians should consult laboratory personnel or package inserts to determine assay capabilities and when additional testing is necessary.

Appropriate use of quantitative testing: Quantitative definitive urine testing is not generally useful to assess prescribed dose adherence and should not be used solely for that purpose; quantitative testing is indicated for variant metabolism, pharmaceutical impurities, complex cases, spiked samples, or to rule out alternative exposure sources.

Policy and AACC guidance indicate qualitative definitive testing is first-line for many monitoring needs; quantitative used selectively.

Covered and not covered scenarios (summary)

Summarizes coverage limits and frequency constraints

CC1 Presumptive testing summary: Presumptive drug screening using urine samples MEETS COVERAGE CRITERIA when performed for indications specified in policy (see CC1); frequency is limited to up to 2 tests per week and up to 24 tests per year per patient.up to 2 per week and 24 per year

Operationalized in the 08/01/2026 policy update.

CC2 Confirmatory/definitive testing summary: Confirmatory/definitive qualitative or quantitative laboratory-based testing meets coverage when specifically requested with physician-documented rationale and when any policy-specified indication is met; definitive panels limited to up to seven drug classes and frequency limited to up to 2 tests per week and up to 24 tests per year.up to 7 drug classes; up to 2/week; up to 24/year

Documentation and drug-class limits required per policy revision.

CC6 General exclusion summary: In all other situations not addressed by CC1 or CC2, presumptive drug screening and definitive drug testing DO NOT MEET COVERAGE CRITERIA.

Default exclusion added to clarify coverage scope.

This policy does not apply to testing performed for legal, employment, or urgent/emergency purposes. Specifically, testing that is state- or federally mandated (forensic or court-ordered), testing performed as a condition of employment or commercial driver certification, and testing that is part of urgent or emergency care are excluded from coverage. Additionally, tests included as part of a per-diem or case-rate reimbursement arrangement are outside the scope of this coverage policy.

A multicenter retrospective study of emergency department testing reviewed >33,000 pre-administration acetaminophen and salicylate screens and found no toxicity diagnoses, leading the authors to conclude that routine psychiatric pre-administration screening for these agents was "unnecessary and wasteful." This example illustrates a low-yield use case where routine screening without clinical indication is discouraged.

The policy cites published analyses showing that routine pre-administration acetaminophen or salicylate testing prior to psychiatric medication administration often yields no actionable findings and may not change management. When evidence demonstrates low clinical utility in a given setting, routine screening should be avoided and testing limited to situations with clear clinical rationale.

Quantitative definitive urine testing has specific, limited uses (for example, identifying variant metabolism, detecting pharmaceutical impurities, confirming spiked samples, or resolving complex cases). It is not supported for routine evaluation of medication dosing or for assessing adherence to a prescribed dose regimen; published guidance states that quantitative testing should not be used to evaluate dosage or adherence in routine pain management contexts.

If this policy conflicts with an applicable government policy (for example, a Medicare Local Coverage Determination, a National Coverage Determination, or a state Medicaid rule), the government policy takes precedence for members covered under that program. Reviewers should consult the referenced government coverage sources when such conflicts may affect determinations.

Laboratory-developed tests (LDTs) are developed and validated in-house by laboratories and are regulated by CMS as high-complexity tests under CLIA '88. LDTs are not FDA-approved or -cleared; the policy notes this as informational and states that FDA clearance or approval is not currently required for clinical use.

The policy includes an explicit default exclusion: in any situation not specifically addressed by the coverage criteria, both presumptive drug screening and definitive drug testing DO NOT MEET COVERAGE CRITERIA. This default (new CC6) means tests outside the listed indications and conditions should be considered not covered unless another applicable policy or government rule applies.

Routine blanket or standing orders that direct testing for all patients in a practice, and same-day duplicate testing of the same drug or metabolite from two different samples (for example, both blood and urine on the same date of service), are not reimbursed. Performing point-of-care presumptive testing and also ordering a separate reference-lab presumptive test on the same specimen is considered duplicative and not reasonable or necessary.

Broad, routine toxicology screening in low-yield settings — for example, the emergency department series cited where thousands of acetaminophen/salicylate tests produced no toxicity diagnoses — is discouraged. Targeted testing based on clinical history, examination, and specific suspicion is preferred to routine blanket screening.

Testing conducted for indications that are not listed in this policy does not meet the coverage criteria. The policy's new general exclusion makes explicit that requests for presumptive or definitive testing outside the specified covered indications and frequency limits should be denied as not meeting medical necessity.

Covered Indications

Monitoring and assessment in multiple clinical contexts

Monitoring and assessment in multiple clinical contexts — coverage and limits

Covered clinical contexts (presumptive up to 2/week and 24/year): Presumptive urine screening is covered for monitoring and assessment in chronic non-cancer pain management, substance use disorder treatment, pregnant individuals at high risk, newborns with maternal substance abuse, organ transplant candidates with substance abuse history, psychiatric conditions, ADHD/disruptive behavior disorders, cancer patients on opioid therapy, and individuals with epilepsy or when substance abuse is in the differential diagnosis.presumptive: up to 2/week and 24/year

Definitive testing covered in these contexts when laboratory-based and physician-documented rationale is provided; see definitive testing limits (≤7 classes).

Definitive testing limits in monitoring contexts: Definitive laboratory-based testing (qualitative or quantitative) is covered in these clinical contexts when specifically requested with documented rationale; panels limited to up to seven drug classes and subject to the policy's frequency limits.definitive: up to 7 classes; up to 2/week; up to 24/year

For SUD monitoring, frequency stratified by abstinence duration as stated in policy.

Monitoring in pain management, substance use treatment, and psychiatric treatment

Monitoring in pain management, substance use treatment, and psychiatric treatment — rationale and context

Evidence and utility: UDT has demonstrated utility in some studies for identifying noncompliance and improving adherence in pain management and substance use treatment programs; evidence strength varies and guideline panels recommend using UDM as part of a broader risk assessment and monitoring strategy.

Guidance supports baseline and risk-stratified monitoring; use definitive testing when specificity is required.

Operational considerations: Testing should be integrated with clinical assessment, use of screening tools, documentation of rationale, and patient counseling; POC immunoassays require awareness of limitations and may prompt definitive testing when results are unexpected.

AACC and consensus guidance referenced for recommended frequency and test selection.

Pre-treatment evaluation when drug interactions are a clinical concern

When to test prior to therapy or procedures: Perform DOA testing prior to initiating therapies or administering medications where known pharmacokinetic interactions are a clinical concern (examples: detecting cocaine before administration of beta-adrenergic antagonists or in patients on antiepileptic drugs that interact with stimulants), when results would alter immediate management.

Document clinical rationale in the medical record.

Baseline testing prior to initiating opioid or other controlled substance therapy and periodic monitoring

Baseline testing prior to initiating opioid or other controlled substance therapy and periodic monitoring during therapy based on patient risk level.

Baseline testing and ongoing monitoring: Perform baseline UDM prior to initiation of opioid therapy; ongoing monitoring frequency should be risk-stratified: low risk—annual (every 6–12 months); moderate risk—every 3–6 months; high risk—every 1–3 months or ≥3 times/year. Definitive testing is preferred for baseline assessment or when results will influence major clinical decisions.risk-stratified frequencies as stated

AACC, consensus panels, and CDC guidance cited; clinicians should document monitoring plans and rationale.

Preoperative screening prior to joint arthroplasty for risk assessment

Preoperative screening prior to joint arthroplasty for risk assessment.

Preoperative UDS for arthroplasty risk assessment: UDS may be used as an initial risk assessment prior to joint arthroplasty to detect opioid or illicit drug use that may affect perioperative outcomes; testing should be interpreted within clinical context and limitations of urine detection windows noted.

Study data support potential utility but also note limitations in detection windows and generalizability.

Testing in seizure patients or before beta-blocker administration

Testing in seizure patients or before beta-blocker administration to detect cocaine or stimulant interactions.

Indication in seizure and adrenergic-therapy contexts: Consider DOA testing in patients with seizure disorders who are on antiepileptic drugs that may interact with cocaine or stimulants, and before administering beta-blockers when cocaine exposure is a possibility, since these interactions can alter management.

Documented clinical concern and rationale required.

Screening and monitoring in pain management, chronic opioid therapy, and opioid treatment programs

Screening and monitoring in pain management, chronic opioid therapy, and opioid treatment programs — testing preferences

Preferred testing approach: Use definitive laboratory-based testing when specificity is required or when immunoassay results are unexpected; OTPs and guideline groups recommend including definitive testing in procedures to address potentially false positive immunoassay results.

SAMHSA and AACC guidance support definitive methods (GC-MS, LC-MS/MS) for confirmation.

Frequency guidance for SUD monitoring: For substance use disorder monitoring, frequency is stratified by abstinence duration: 0–30 days: ≤1/week; 31–90 days: 1–3/month (no more than 3 in a month); >90 days: 1–3 every three months (no more than 3 in a three-month period).as stated

Physician-documented rationale required for definitive testing frequency.

Screening, monitoring, or evaluation when clinically indicated

Screening, monitoring, or evaluation when clinically indicated (examples and contexts).

Situations where targeted testing is appropriate: Targeted testing is appropriate for pre-employment/federal testing, random testing, reasonable suspicion/cause testing, post-accident testing, return-to-duty or follow-up testing, risk assessment prior to initiating opioid therapy, acute psychosis or suspected stimulant-induced states (e.g., status epilepticus), and prenatal screening per professional guidance; select specimen type and method per clinical context (urine, oral fluid, hair) and follow applicable federal/state rules.

SAMHSA, HHS, VA/DoD, and ACOG guidance referenced; oral fluid testing is acceptable for certain federal testing contexts per SAMHSA.

Prescription drug monitoring and therapeutic drug monitoring panels

Prescription drug monitoring and therapeutic drug monitoring panels — examples of proprietary platforms and specimen types.

Proprietary panel examples: Proprietary assays vary widely in panel size and specimen type (examples in the policy include Cordant CORE™ [urine LC-MS/MS, 31-drug panel], UCompliDx [capillary blood, 14+ classes], ComplyRX/Precision Toxicology [urine LC-MS/MS, 65 drugs], and other large definitive urine LC-MS/MS panels up to 120+ drugs); these are listed with HCPCS/PLA codes in the coding table.

Many proprietary panels exceed the policy's 7-class coverage limit; coverage determination depends on policy exclusions and specific billing codes.

Billing and identification: When ordering or billing proprietary or laboratory-developed tests, include the specific HCPCS/PLA code and laboratory/manufacturer identifier as listed to ensure correct identification and claims processing.

Policy coding table enumerates proprietary HCPCS/PLA codes; inclusion in coding table does not imply coverage where policy exclusions apply.

Situations specified in CC1 and CC2 where presumptive or confirmatory testing is indicated and documented

Situations specified in CC1 and CC2 where presumptive or confirmatory testing is indicated and documentation requirements.

Documentation and ordering requirement for definitive testing: Laboratory-based definitive (confirmatory) drug testing must be specifically requested by the treating physician and accompanied by documented clinical rationale in the patient's medical record for coverage to apply.

Policy revision clarifies documentation requirement and limits definitive panels to up to seven drug classes.

Confirmatory testing scope: Confirmatory/definitive testing is covered up to seven drug classes when the above documentation and clinical indications are met; frequency limits (up to 2/week and 24/year) apply to both presumptive and definitive testing.up to 7 drug classes; up to 2/week; up to 24/year

Providers should reference policy criteria and coding table when ordering and billing confirmatory tests.

Frequency Limits and Panel Size

Overall frequency limit for presumptive or definitive drug testing (operational)

Operational limitPresumptive or definitive drug testing: up to 2 tests per patient per week; up to 24 tests per patient per year.

Applies toBoth presumptive urine screening and laboratory definitive/confirmatory testing when performed for covered indications.

Documentation noteConfirmatory/definitive testing should be supported by documentation of clinical rationale in the patient record.

Presumptive monitoring frequency by risk

Low riskApproximately once per year (perform UDM at baseline; low-risk monitoring ~annual).

Moderate riskUp to two times per year (AACC/consensus: two or more times per year).

High riskUp to three to four times per year (guidance: three or more times per year; AMDG: three to four per year).

Definitive testing frequency guidance for substance use disorder monitoring across phases of abstinence/stability

0–30 days abstinenceRandom definitive testing not to exceed one test per week.

31–90 days abstinenceRandom definitive testing 1–3 tests per month (no more than 3 definitive tests in one month).

>90 days abstinenceDefinitive testing 1–3 tests every three months (no more than 3 definitive tests in a three-month period).

UDT/UDM frequency ranges by risk per guidelines

Low-risk UDT/UDMEvery 6–12 months (baseline then at least annually for low-risk patients).

Moderate-risk UDT/UDMEvery 3–6 months (two or more times per year; AACC: two or more).

High-risk UDT/UDMEvery 1–3 months or ≥3 times/year (perform testing more frequently; may be at each visit/refill).

Urine testing (random) minimum frequency guidance

Minimum random urine testing (AACC)Random testing at minimum 1–2 times/year for low-risk patients; increase frequency with higher risk.

Baseline requirementPerform baseline UDM prior to initiating opioid therapy.

Use caseRandom testing recommended over scheduled testing by some specialty groups (Texas Pain Society, consensus panels).

UDT frequency summary (low/moderate/high) across guidelines

Low-risk summaryUp to 1 test per year (variously stated as annual or 1 per year).

Moderate-risk summary2–4 tests per year (guidelines vary; commonly 2 per year up to 3–4 per year).

High-risk summary3–4+ tests per year or testing at each visit/refill depending on guideline and clinical judgment.

Substance use disorder treatment monitoring cadence (initial frequent random testing then taper)

Initial phaseFrequent random testing initially in SUD treatment (e.g., at least weekly while unstable).

Stabilization phaseDecrease testing frequency once stable (e.g., monthly or per program guidance).

DocumentationTesting cadence and results should be documented in the patient's record to support monitoring decisions.

UDT use as part of pre-initiation risk assessment for opioid therapy

Pre-initiation assessmentUse UDT as part of comprehensive risk assessment prior to initiating opioid therapy (baseline testing recommended).

ReevaluationReevaluate risk and repeat UDT per risk-stratified schedule and clinical judgment.

Guideline supportRecommended by HHS and various specialty guideline groups as part of risk assessment and monitoring.

Operational restatement of frequency limits (policy-level)

Policy operational limitAt the policy level: presumptive and confirmatory (definitive) testing are limited to up to 2 per week and up to 24 per year per patient.

Applies to both test typesThis operational limit is stated for both CC1 (presumptive urine screening) and CC2 (confirmatory/definitive testing).

Reimbursement implicationClaims exceeding these frequency limits may not meet coverage criteria unless documented exceptions apply per policy.

Coding and Procedure Codes

Not reimbursed HCPCS codesHCPCSNot Covered

HCPCS definitive drug class codes

Any HCPCS definitive drug class codes as defined in the BCBSLA Professional Provider Office Manual.

Applicable CPT/HCPCS procedure codesCPT

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 (eg, utilizing immunoassay [eg, 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 (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation when performed, per date of service
80307	Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) 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

Covered CPT Codes (presumptive and definitive drug testing)CPTCovered

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 (eg, utilizing immunoassay), includes sample validation when performed, per date of service
80306	Drug test(s), presumptive; read by instrument assisted direct optical observation (eg, utilizing immunoassay), includes sample validation when performed, per date of service
80307	Drug test(s), presumptive; by instrument chemistry analyzers (eg, utilizing immunoassay), 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
80326	Amphetamines; 5 or more

1–10 of 61

1/7

Listed Proprietary/PLA/Other HCPCS Codes and Lab-identified TestsHCPCS

0011U	Cordant CORE™ — Prescription drug monitoring, evaluation of drugs present by LC-MS/MS, urine, 31 drug panel, quantitative results, per date of service
0051U	UCompliDx — Prescription drug monitoring, 14 or more classes of drugs, definitive tandem mass spectrometry with chromatography, capillary blood, quantitative report including steady-state range when detected
0054U	Firstox Laboratories — Drug test(s), definitive, 90 or more drugs or substances, definitive chromatography with mass spectrometry, urine, report of presence/absence with interaction descriptions
0082U	Precision Toxicology/Precision Diagnostics — Prescription drug monitoring, 65 common drugs by LC-MS/MS, urine, each drug reported detected or not detected (ComplyRX)
0093U	Claro Labs — Drug assay, presumptive, 30 or more drugs or metabolites, urine, LC-MS/MS, includes sample validation
0227U	Aspenti Health — Drug assay, definitive, 120 or more drugs and metabolites, urine, quantitative LC-MS/MS, includes specimen validity and algorithmic analysis describing risks for significant patient-adverse events
Proprietary	Multiple proprietary tests and manufacturer names listed (e.g., Genotox Laboratories LTD, Cordant Health Solutions, Elite Medical Laboratory Solutions, Precision Toxicology, Claro Labs, Aspenti Health, Phenomics Health, Astraeus Lab, Soft Landing Labs)

Policy CPT/PLA coding updates and removalsCPT | PLA

0603U	CPT code added (description per coding table)
0517U	Revised CPT code (manufacturer removed from proprietary test name)
0587U	CPT code added
0518U	CPT code added
0519U	CPT code added
0520U	CPT code added
0079U	Code removed per client request
0143U	PLA code removed
0144U	PLA code removed
0145U	PLA code removed

1–10 of 16

1/2

Maximum definitive panel size

Maximum definitive panel sizeDefinitive/confirmatory testing coverage limited to panels of up to 7 drug classes.

ContextPanels larger than seven drug classes are explicitly listed as not covered in the policy exclusions.

Documentation requirementLaboratory-based definitive testing must be specifically requested with physician-documented rationale.

Annual and weekly testing limit (2/week; 24/year)

Weekly limitMaximum of 2 tests per patient per week (applies to presumptive and definitive testing).

Annual limitMaximum of 24 tests per patient per year (applies to presumptive and definitive testing).

Policy referenceThese limits were added to CC1 and CC2 in the 08/01/2026 revision notes.

THC immunoassay federal cutoff level (50 ng/mL)

THC immunoassay federal cutoffImmunoassay cutoff for THC (federal/SAMHSA reference): 50 ng/mL.

Clinical relevanceCutoff reduces false positives from second-hand exposure; lower cutoffs (e.g., 20 ng/mL) may produce positives in poorly ventilated exposure scenarios.

Assay targetImmunoassays detect THC metabolites (delta-9-THC metabolite) rather than parent THC.

Cocaine (benzoylecgonine) assay cutoff range (150-300 ng/mL)

Cocaine (benzoylecgonine) cutoff rangeCommon immunoassay cutoff range for benzoylecgonine: 150–300 ng/mL (DRI Cocaine Metabolite Assay).

Metabolite noteBenzoylecgonine is the major urinary metabolite and is typically the analyte tested to detect cocaine use.

Detection windowBenzoylecgonine may be detectable in urine for several days depending on use pattern.

Amphetamine assay cutoffs (DRI®) example values

Amphetamine (DRI®) cutoffDRI® Amphetamines Assay cutoff example: amphetamine 500 ng/mL; methamphetamine 1000 ng/mL.

Concordance noteReported concordance with GC/MS at the 500 ng/mL cutoff ~58% for the DRI assay; positive immunoassay results should be confirmed by a non-immunoassay method.

Cross-reactivityNumerous over-the-counter medications and supplements can cause false-positives on amphetamine immunoassays.

Morphine urine threshold historical SAMHSA change (2000 ng/mL)

Morphine urine threshold (SAMHSA historical change)SAMHSA raised the urine morphine threshold from 300 ng/mL to 2000 ng/mL to reduce poppy seed false-positives.

Heroin detectionHeroin use can be distinguished by testing for 6-MAM (6-acetylmorphine), which has a short half-life before metabolizing to morphine.

Use implicationHigher morphine cutoff reduces false positives from dietary sources but clinicians may test for 6-MAM when heroin use is suspected.

Panel size thresholds for proprietary tests (examples ranging broadly)

Proprietary panel sizesExamples of proprietary tests list panel sizes ranging broadly (e.g., 14+ classes, 31-drug panels, 65 drugs, 90+ drugs, 120+ drugs).

Coverage implicationProprietary panels that exceed the policy limit of up to 7 drug classes are not covered unless otherwise specified.

Billing noteWhen billing for proprietary assays, include the specific HCPCS/PLA code and laboratory/manufacturer identifier per policy guidance.

Provider Actions, Documentation, and Billing Guidance

Prior Authorization

Request definitive testing with physician-documented rationale

Laboratory-based definitive (confirmatory) drug testing must be specifically requested by the treating physician and supported in the medical record with the physician’s documented clinical rationale; coverage for definitive testing is limited to panels of up to seven drug classes and the policy frequency limits (up to 2 per week and 24 per year).

Definitive testing must be laboratory-based and specifically requested.
Physician-documented rationale must be in the patient’s medical record.
Coverage limited to up to seven drug classes and frequency limits (≤2/week; ≤24/year).

Prior Authorization

Confirmatory testing required when results affect major decisions

Obtain confirmatory/definitive testing (e.g., GC‑MS, LC‑MS/MS) when results will inform major clinical or nonclinical decisions — for example, when specific opioid or metabolite identification affects treatment, legal, or administrative outcomes; limit confirmatory testing to situations expected to affect patient management.

Recommended when results will inform major decisions or require specific opioid identification.
Limit confirmatory testing to scenarios expected to change management.

Prior Authorization

Include procedures for confirmatory testing and discrepant results

When definitive confirmatory testing is pursued, laboratories and clinical programs should include procedures to address potential false positives/negatives and discrepant results, selecting an appropriate confirmatory modality (e.g., GC‑MS or LC‑MS) tailored to patient needs.

Include procedures to address potentially false positive immunoassay results and discrepant findings.
Select confirmatory modality (GC‑MS, LC‑MS/MS) based on clinical context and assay capabilities.

Prior Authorization

Comply with HHS authorization and panel requirements for federal testing

Follow HHS requirements for federal workplace and oral fluid testing: each specimen must be tested for marijuana and cocaine, and additional drug or specimen‑validity testing by an HHS‑certified laboratory requires prior authorization except where the rule permits (e.g., d,l stereoisomer determinations).

Federal HHS rule requires testing each specimen for marijuana and cocaine.
Additional drug/specimen validity tests by an HHS‑certified lab require prior authorization except specified exceptions.

Billing Rule

Bill proprietary assays using listed HCPCS/PLA codes

Use the specific HCPCS/PLA (proprietary) codes listed in the policy when billing for proprietary assays (examples include 0011U, 0051U, 0054U, 0082U, 0093U, 0227U); include the lab/manufacturer identifier as required.

Bill proprietary assays using the HCPCS/PLA code listed for that test (e.g., 0011U, 0051U, 0054U, 0082U, 0093U, 0227U).
Include laboratory/manufacturer identifier when submitting claims for proprietary tests.

Billing Rule

Reference the policy coding table for current codes

Reference the policy coding table for the current CPT/PLA/HCPCS codes when submitting claims; coding tables were updated (operational coding changes noted in revision history) and may change over time.

Policy coding table updated with code additions/removals—check current table before billing.
Procedure codes in the policy are reference‑only and may not be all‑inclusive.

Step Therapy

Duplicate presumptive testing on same specimen not reimbursed

When both point‑of‑care presumptive testing and reference‑laboratory presumptive testing are performed on the same specimen (or more than one presumptive test result per date of service), only one presumptive test is reimbursed; same‑day testing of the same drug/metabolite from two different samples is not reimbursed.

Not reimbursed to perform POC presumptive testing and also order presumptive testing from a reference lab on the same specimen.
Same‑day testing of the same analyte from two different samples (e.g., blood and urine) is not reimbursed.

Step Therapy

Screen first, then perform orthogonal/definitive confirmatory testing

Initial testing may be performed with an immunoassay presumptive screen; follow with orthogonal or definitive testing (e.g., mass spectrometry) when confirmation is needed for clinical management or when results are unexpected.

Use presumptive immunoassay screening first when appropriate.
Follow a positive or unexpected presumptive result with orthogonal or definitive testing (GC‑MS/LC‑MS) as indicated.

Step Therapy

Use immunoassay first; confirm with definitive methods when required

Perform immunoassay (POC or lab) as an initial screen but obtain definitive testing (GC‑MS, LC‑MS/MS) when needed for accurate identification prior to major management changes; do not rely solely on immunoassay positives when clinical decisions depend on the result.

Use immunoassay for rapid screening; obtain definitive MS‑based confirmation when specificity is required.
Avoid major long‑term management changes based on POC immunoassay results without definitive confirmation.

Step Therapy

Step therapy: none specified

No step therapy requirements are specified in this policy.

Documentation Required

Document medical necessity and rationale for definitive testing in the record

Document medical necessity for testing in the patient’s medical record, including relevant medical history, physical examination findings, and the clinical rationale when requesting definitive testing; confirmatory testing must be supported by documentation in the record.

Medical record must include history, exam, and documentation supporting medical necessity.
Physician rationale must accompany requests for laboratory‑based definitive testing.

Documentation Required

Document test type, methodology, and interpretation

Record the test type, testing methodology (presumptive immunoassay vs definitive MS/GC), and interpretation in the medical record; consult or document laboratory/toxicologist interpretation for complex or unexpected results.

Document the assay methodology and whether the test was presumptive or definitive.
Obtain and document laboratory toxicologist input when interpretation is uncertain.

Documentation Required

Document interpretation and rationale for confirmatory testing

When pursuing confirmatory testing, document the interpretation discussion with the patient and the clinical rationale for confirmatory testing (including why the same specimen is being used for confirmation); record the decision process that led to confirmation.

Document discussion with the patient when unexpected screening results occur.
Document why confirmatory testing was requested and the rationale for using the same sample.

Documentation Required

Document clinical monitoring and risk assessment to support testing

Document clinical monitoring elements that justify testing frequency: pain intensity, function, adverse events, adherence assessments, and use of risk tools (e.g., SOAPP, Opioid Risk Tool) to support the testing plan and intervals.

Record pain intensity, functioning, adverse events, and adherence in the chart.
Document use of risk assessment tools to justify monitoring frequency.

Documentation Required

Request confirmatory MS/GC testing when specimen validity or unexpected results occur

Be aware of laboratory test characteristics and specimen validity issues; when validity concerns or unexpected results arise, request confirmatory mass spectrometry/GC or LC testing and document specimen‑validity findings.

Request MS/GC confirmation for unexpected immunoassay results or when specimen validity is in question.
Document abnormal specimen characteristics (odor, color, adulterant reactions) and any additional testing performed.

Billing Rule

Include proprietary test code and lab identifier on claims

Include the specific HCPCS/PLA code and the laboratory/manufacturer identifier on claims when submitting for proprietary or lab‑identified tests to ensure correct identification and billing.

List the proprietary HCPCS/PLA code (e.g., 0011U, 0051U, 0054U, 0082U, 0093U, 0227U) on the claim.
Include the lab/manufacturer identifier as provided in the policy coding table.

Denial Risk

Noncovered testing and documentation gaps may trigger denial

Failure to follow coverage scope (tests or indications not addressed by the policy), ordering documentation, or billing guidance may result in denial; specimen validity testing and proprietary platform testing are specifically noted as non‑covered triggers for denial.

Tests and indications not addressed by the policy are not covered and may be denied.
Specimen validity testing and certain proprietary platforms are not covered per policy.

Denial Risk

Confirm positive presumptive/POC results with definitive testing

Confirm presumptive or point‑of‑care positive results with definitive testing (mass spectrometry/GC) when clinical decisions depend on the result; do not rely solely on POC positives for management decisions.

Obtain definitive confirmation for POC/immunoassay positives that will influence clinical or administrative decisions.
Document confirmatory testing when used to verify POC findings.

Denial Risk

Do not use testing punitively or overuse beyond guideline indications

Avoid using toxicology testing punitively or overusing testing beyond guideline‑based indications; disregarding recommendations for confirmatory testing when results will inform major decisions may lead to inappropriate care and payer restrictions.

Do not use testing as a punitive measure; use results to inform and improve patient care per CDC guidance.
Follow recommendations for confirmatory testing when results will affect management.

Denial Risk

Confirm unexpected immunoassay results with definitive testing

Obtain definitive confirmatory testing when immunoassay results are unexpected or inconsistent with the clinical picture to avoid inappropriate clinical decisions; societies recommend definitive testing in such cases.

If immunoassay results conflict with history or expectation, request definitive MS/GC confirmation.
Document the reason for confirmatory testing and the clinical context.

Note

Follow federal HHS panel and authorization rules for workplace testing

Federal workplace testing panels require testing each specimen for marijuana and cocaine; additional analytes or specimen‑validity testing by an HHS‑certified lab must follow HHS authorization rules to avoid noncompliance.

Ensure federal workplace oral fluid specimens are tested for marijuana and cocaine per HHS rule.
Obtain required authorizations for additional testing or specimen validity analyses when applicable.

Billing Rule

Ensure complete and current coding to avoid claim review

Incomplete or outdated coding on claims may prompt claim review or denial; procedure codes in this policy are provided as a reference and may not represent all billable codes—verify codes and include required identifiers.

Procedure codes in the policy are a general reference and may not be all‑inclusive.
Verify current codes and include proprietary test identifiers when applicable.

Documentation Required

Treating physician must specifically request and document confirmatory testing

For any laboratory‑based definitive (confirmatory) drug testing request, the treating physician must specifically request the test and document the clinical rationale in the medical record; this documentation supports coverage determinations.

Treating physician must specifically request laboratory‑based definitive testing.
Document the clinical rationale in the patient’s record to support coverage.

Denial Risk

Default exclusion — tests outside listed indications are not covered

Presumptive and definitive drug testing for indications not listed in the policy are not covered (default exclusion CC6); ordering such tests risks denial.

CC6: tests in situations not addressed by policy DO NOT MEET COVERAGE CRITERIA.
Avoid ordering tests for indications outside the policy’s listed coverage scenarios.

Ordering and Operational Requirements

Note

Order laboratory‑based definitive testing with proper documentation

Order definitive laboratory testing only when it is specifically requested and justified; ensure appropriate specimen collection and ordering practices are documented in the medical record.

Note

Choose POC vs lab testing based on clinical need; confirm positives

Select point‑of‑care versus laboratory definitive testing based on clinical need; a positive POC immunoassay should prompt confirmatory definitive testing when required for management.

Note

Know panel composition and POC limitations; consult package inserts

Clinicians should be familiar with the composition and limitations of panels they order and consult package inserts or laboratory personnel when using POC tests to understand assay limits.

Note

Choose testing and collection per patient and clinical assessment

Select testing type and collection method on a patient‑by‑patient basis and integrate testing with clinical assessment and risk tools to justify the test.

Note

Order tests using clinical judgment and guideline recommendations

Use clinical judgment when ordering tests; specialty guidance recommends integrating screening tools, PDMP checks, and referral to specialists for high‑risk patients.

Billing Rule

Reference lab/manufacturer and test code for proprietary/LDT orders

When ordering proprietary or LDT assays, reference the lab/manufacturer and include the test‑specific HCPCS/PLA code listed in the policy to ensure correct identification and billing.

Prior Authorization

Treating physician must specifically request and document definitive testing

The treating physician must specifically request laboratory‑based definitive (confirmatory) testing and document the clinical rationale in the medical record for coverage and reimbursement to apply.

Not Covered — Exclusions

Procedures and assays that generate panels larger than seven drug classes, proprietary platform tests (for example, those named in the policy), and specimen validity assays (such as urine specific gravity, creatinine, pH, oxidant testing, or genetic identity testing) are listed as not covered. These items are excluded because they exceed the policy's panel-size limits or because specimen-validity testing is explicitly not reimbursed under the coverage criteria.

The policy highlights the multicenter VA review that found routine psychiatric pre-administration acetaminophen and salicylate screening produced no toxicity diagnoses and deemed the testing unnecessary; this is cited as an illustrative example of low clinical value screening in that setting.

Based on the cited retrospective analyses, routine acetaminophen or salicylate screening prior to psychiatric medication administration is generally unnecessary and unlikely to change management; such testing should be reserved for cases with specific clinical concern or clear rationale.

Quantitative urine testing performed solely to assess whether a patient is taking the prescribed dose (i.e., to measure adherence by concentration) is not recommended and is not covered as a routine use. Quantitative assays have defined roles (variant metabolism, impurities, complex forensic questions) but are not appropriate for routine dosing or adherence verification.

Universal routine urine drug screening in pregnancy is controversial. ACOG recommends universal validated verbal screening and notes that routine laboratory screening is not uniformly recommended; testing should comply with state law and be performed with informed patient consent.

Procedure and billing codes shown in this policy are provided as a general reference and may not be exhaustive. Coding lists in the policy are not guaranteed to include all applicable codes; providers should rely on current coding resources and the policy coding table when submitting claims.

The policy introduces a new explicit not-covered default (CC6): unless an indication is specifically listed in the coverage criteria, presumptive and definitive drug testing DO NOT MEET COVERAGE CRITERIA. This creates a clear operational presumption against coverage for unlisted indications.

Definitions

DOA (Drugs of abuse) definition and scope

DefinitionDOA (Drugs of abuse): a drug, chemical, or plant product known to be misused for recreational purposes; may include prescription medications.

ScopePolicy focuses on clinical outpatient toxicology (urine/oral fluid primarily) and excludes forensic testing and therapeutic drug monitoring.

Common specimensUrine is the most commonly tested biological specimen in outpatient drug testing; other specimens include blood, hair, and saliva.

Presumptive testing definition (immunoassay screening)

Presumptive testing definitionScreening tests (often immunoassays) that identify use or non-use of a drug or drug class but may not distinguish structural isomers and have higher false-positive/negative risk.

SettingUsed in point-of-care (POC) or laboratory settings; POC provides rapid results but has lower sensitivity/specificity than definitive methods.

Follow-upPositive presumptive results generally require confirmatory definitive testing when results affect management.

Definitive testing definition (GC-MS, LC-MS/MS) high specificity

Definitive testing definitionLaboratory-based confirmatory methods (e.g., gas chromatography-mass spectrometry [GC-MS], liquid chromatography-mass spectrometry [LC-MS], LC-MS/MS) that identify specific drugs and metabolites with higher specificity and sensitivity.

Use casesRecommended when results will inform major clinical/nonclinical decisions or when immunoassay results are unexpected or discordant with history.

Analytic advantageMS-based assays can identify specific drugs/metabolites and reduce false-positive/negative interpretations compared with immunoassays.

Definitive testing analytical methods (GC-MS, LC-MS, LC-MS/MS) description

Analytical methodsDefinitive testing typically uses chromatographic and spectroscopic methods, including gas chromatography (GC), liquid chromatography (LC), and tandem mass spectrometry (MS/MS).

Gold standardMS-based assays are traditionally considered the gold standard despite higher labor/time intensity.

Clinical applicationUsed for definitive identification of drugs and metabolites, especially when specificity is required.

Presumptive/Immunoassay testing definition and limitations

Immunoassay naturePresumptive immunoassays (laboratory or POC) screen for drug classes with variable sensitivity and cross-reactivity; they may miss or cross-react with specific agents.

LimitationsHigher false-positive and false-negative rates than definitive methods; interpretation requires awareness of cross-reactants and package insert limitations.

RoleUseful for rapid screening; positive results that will affect management should be confirmed with definitive methods.

Definitive testing (lab-based confirmatory methods) definition duplicate technical note

Confirmatory/definitive duplicate noteDefinitive testing (GC-MS/LC-MS) is used to confirm unexpected immunoassay results and to provide definitive identification when required.

Program proceduresPrograms should include procedures addressing potential false positives and sample handling when pursuing definitive testing.

When requestedLaboratory-based definitive testing must be specifically requested and documented by the treating physician for coverage in many scenarios.

Presumptive (immunoassay) testing definition (POC or lab immunoassays)

POC vs lab immunoassaysPOC immunoassays offer rapid results but share sensitivity/specificity limitations with laboratory immunoassays; clinicians must consult package inserts or lab personnel.

Specimen typesPOC tests may use urine or saliva; performance may be poorer with saliva for some agents (higher false-negative rates among smokers).

Interpretive cautionPositive POC results should prompt confirmatory testing when results will influence management.

Adulterated specimen definition

Adulterated specimen definitionA specimen altered by the patient, evidenced by abnormal characteristics (e.g., unusual odor/color), presence of adulterants, or abnormal concentrations of normal constituents (e.g., nitrite in urine).

ResponseAbnormal or adulterated specimens may prompt additional testing per HHS rules and program procedures.

ImplicationSpecimen validity issues should be documented and may necessitate recollection or confirmatory analyses.

LDT definition — laboratory-developed test and CLIA regulation context

LDT definitionLaboratory-developed test (LDT): a laboratory-specific test developed and validated in-house; regulated by CMS under CLIA as high-complexity testing and not FDA-approved.

Regulatory noteFDA clearance/approval is not currently required for clinical use of LDTs per policy text.

Billing considerationWhen ordering proprietary or LDT assays, reference the lab/manufacturer and specific HCPCS/PLA code as listed for billing.

Confirmatory/definitive drug testing definition (up to seven drug classes)

Confirmatory testing definition with limitsLaboratory-based definitive (confirmatory) drug testing: qualitative or quantitative testing performed when specifically requested with documented rationale; coverage limited to panels up to seven drug classes.

Frequency constraintSubject to overall frequency limits (up to 2/week; up to 24/year) per policy revisions.

Documentation requirementTreating physician must specifically request and document the rationale in the medical record for coverage of definitive testing.

Background and Evidence Summary

Drug testing is commonly used for monitoring in pain management, substance use disorder programs, psychiatric care, and pre-procedural assessments. However, immunoassay-based presumptive tests have recognized limitations in sensitivity and specificity, and guidance from specialty societies supports baseline testing and risk-stratified ongoing monitoring with confirmatory definitive testing (GC-MS, LC-MS/MS) when results will affect management.

The policy references multiple evidence sources and guideline bodies, including AACC/AAPM guidance, CDC opioid prescribing guidance, and specialty consensus panels. These references underpin recommendations for baseline testing, risk-stratified frequency, and use of definitive methods where accuracy materially affects clinical decisions.

An extensive evidence base is cited in the policy (refs. 59–106+), encompassing primary studies and clinical guidelines that informed the coverage criteria. These references include analyses of assay performance, clinical utility studies, and major guideline statements that support the policy's frequency limits, confirmatory testing recommendations, and exclusions.

Stats-bar source metrics referenced in policy

Statistic - max testsMaximum covered presumptive or definitive tests per patient: 2 per week; 24 per year.

Statistic - panel sizeMaximum covered definitive test panel size: up to 7 drug classes.

Evidence referencesGuideline and consensus sources cited throughout policy (AACC, CDC, SAMHSA, AMDG) support risk-stratified testing frequencies.

Revision History

2026-08-01policy_revisionLatest

Added operational frequency limits '(up to 2 per week and 24 per year)' to CC1 and CC2; clarified confirmatory testing scope to 'up to seven drug classes' and required laboratory-based definitive testing specifically requested with physician-documented rationale; updated background, guidelines, and evidence references following Clinical Advisory Board review.

2026-01-01coding_update

Off-cycle coding modification: added CPT code 0603U and revised CPT code 0517U (removed manufacturer from proprietary test name).

2025-10-01coding_update

Added CPT code 0587U to the policy coding table.

2025-07-01policy_review

Policy reviewed and updated: background, guidelines, and recommendations were updated following review on 07/01/2025.

2024-10-01coding_update

Off-cycle coding modifications: added CPT codes 0517U, 0518U, 0519U, and 0520U.

2024-07-01coding_update

Client requested removal of CPT code 0079U.

2023-10-01coding_update

Off-cycle review replaced Newstar Medical RiskViewRx with CareView360 in CC4 and removed PLA codes 0143U–0150U; added PLA code 0328U.