Currentblue cross blue shield - tennesseePolicy N/A

Prescription Medication and Illicit Drug Testing in the Outpatient Setting (BlueCare) – T2015

Defines coverage, limitations, frequencies, specimen types, and billing guidance for presumptive and definitive outpatient drug testing (clinical toxicology) for BlueCross BlueShield of Tennessee (BlueCare). Excludes forensic testing, employment-related testing, and urgent/emergency-only use.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyPrescription Medication and Illicit Drug Testing in the Outpatient Setting (BlueCare) – T2015

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionDocument the clinical rationale and supporting medical record details (history, exam, prior test results, and treating physician rationale) to support medical necessity for definitive testing.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

<=7Definitive covered drug classes

24Presumptive optical annual limit

12Presumptive instrument annual limit

12Definitive testing annual limit

Policy summary & scope

Background: This policy addresses clinical (non‑forensic) outpatient toxicology testing (presumptive and definitive) and excludes forensic testing, employment-related testing, and urgent/emergency-only use. It applies to outpatient specimens (urine or oral fluid; blood only for anuric chronic renal failure patients) and focuses on clinical monitoring and diagnosis rather than therapeutic drug monitoring (TDM) or legal/forensic purposes.

Scope summary: Covered populations include patients treated for chronic non‑cancer pain on opioid therapy (monitoring and pre‑initiation assessment), pregnant individuals at high risk for substance use, newborns with maternal substance use history or altered maternal mental status, organ transplant candidates with substance use history, individuals with suspected or diagnosed mental illness, patients with ADHD or disruptive behavior disorders, cancer patients on opioids, individuals with epilepsy, and patients in substance use disorder (SUD) treatment. Documentation requirements: treating physician rationale, relevant history, exam findings, prior test results, and rationale for definitive testing must be in the medical record to support medical necessity. Policy status/metadata: Payer = BlueCross BlueShield of Tennessee (BlueCare); Policy subject = Outpatient prescription medication and illicit drug testing (urine/oral fluid/blood); Status = CURRENT; Last review = 2025-02-12; coverage limits and frequency rules specified in policy.

Quick facts / thresholds

Definitive covered drug classes<= 7 drug classes (covered); >7 drug classes not covered

Presumptive Optical Testing - Annual LimitNot to exceed 24 tests per year

Presumptive Instrument-Based Testing - Annual LimitNot to exceed 12 tests per year

Definitive Testing - Annual LimitNot to exceed 12 tests per year

Specimen types coveredUrine or oral fluid generally; blood specimens covered only for patients with anuric chronic renal failure

Medical necessity criteria

Presumptive drug screening (urine) - Covered situations

Presumptive drug screening using urine samples (qualitative, semi-quantitative or quantitative) MEETS COVERAGE CRITERIA in any of the following situations:

ANY of the following

Chronic opioid pain therapy monitoring
- Assessment prior to or during chronic opioid therapy: To assess an individual being treated for chronic, non-cancer pain when clinical evaluation (history/signs/symptoms) suggests use of non-prescribed medications or illegal substances
- Prior to initiating therapy: Prior to initiating chronic opioid pain therapy in chronic non-cancer pain to determine if the individual has been exposed to controlled substances or illicit drugs
- Routine monitoring for compliance: To verify compliance or identify undisclosed drug abuse as part of routine monitoring for individuals receiving prescription opioid therapy; random testing interval and drugs selected should be based on individual's history, condition, and treatment, as documented in the medical record
- Monitoring frequency by risk level (as defined by a risk assessment tool)
  - Low risk frequency: Low risk: up to one time per year after initiation of therapy
  - Moderate risk frequency: Moderate risk: up to two times per year after initiation of therapy
  - High risk frequency: High risk: up to four times per year after initiation of therapy
- Aberrant behavior testing: Testing at the time of visit meets coverage criteria for individuals with aberrant behavior (e.g., lost prescriptions, multiple requests for early refills, opioids from multiple providers, unauthorized dose escalation, apparent intoxication)
Pregnancy and newborn: In pregnant individuals at high-risk for substance abuse when suspicion exists based on screening questions or PDMP information, documented in medical record; In newborns when there is a history of maternal substance abuse or agitated/altered mental status in the birthing parent
Transplant candidates: In candidates for organ transplant with history of substance abuse to demonstrate abstinence prior to transplant
Mental illness: In individuals with suspicion of or diagnosis of mental illness (examples provided)
ADHD: In individuals with attention-deficit hyperactivity and disruptive behavior disorders
Cancer patients on opioids: In cancer patients on opioid pain medication
Epilepsy: In individuals with epilepsy
Monitoring for substance abuse treatment (frequency requirements)
- 0–90 days abstinence frequency: For patients with 0–90 consecutive days of abstinence: random qualitative drug testing frequency 1–2 per week
- >90 days abstinence frequency: For patients with >90 consecutive days of abstinence: random qualitative drug testing frequency 1–3 per month
Substance abuse differential: When substance abuse is in the differential diagnosis of the presenting condition

Definitive (confirmatory) drug testing - Covered criteria

Confirmatory/definitive qualitative or quantitative drug testing (up to seven drug classes) MEETS COVERAGE CRITERIA when laboratory-based definitive testing is specifically requested, rationale documented by treating physician, and any of the following are met:

ANY of the following

Discordant presumptive result: Result of presumptive screen is different than suggested by medical history, clinical presentation, or patient's statement (examples: negative for prescribed meds, positive for prescription drug not prescribed, positive for illegal drug)
SUD monitoring / frequency thresholds
- 0–30 consecutive days abstinence: random definitive testing frequency not to exceed 1 test per week
- 31–90 consecutive days abstinence: random definitive testing frequency 1–3 tests per month; no more than 3 definitive tests in one month

Definitive/Proprietary/Panel limits - Not covered

Exclusions for definitive and proprietary tests

Not covered - panels >7 and proprietary tests: When laboratory-based definitive testing is requested for panels larger than seven drug classes, confirmatory/definitive testing DOES NOT MEET COVERAGE CRITERIA; Confirmatory/definitive or presumptive testing using proprietary tests (e.g., CareView360) DOES NOT MEET COVERAGE CRITERIA

Specimen validity testing - Not covered

Specimen validity testing exclusions

Specimen validity testing not covered: Specimen validity testing (e.g., urine specific gravity, urine creatinine, pH, urine oxidant level, genetic identity testing such as NextGen Precision™ Testing) DOES NOT MEET COVERAGE CRITERIA

General/Other situations - Not covered

Default exclusion

General exclusion: In all other situations not addressed above, presumptive drug screening and definitive drug testing DO NOT MEET COVERAGE CRITERIA

Codes and coding guidance

Covered presumptive drug screening CPT/HCPCSmixedCovered

80320	Drug test, presumptive, any number of drug classes; non-instrumented (e.g., immunoassay)
G0659	Specimen handling and transport for drug testing (when applicable)

Definitive testing coverage is limited to laboratory-based confirmatory/definitive qualitative or quantitative drug testing for panels of seven or fewer drug classes. Proprietary tests and panels larger than seven drug classes are not covered. Codes within the 80320-80377 range and related G-code(s) such as G0659 are included in the covered definitive and presumptive coding guidance where applicable; proprietary LDT codes (for example 0007U and 0011U) are noted but subject to the policy exclusion for proprietary tests.

Billing & documentation requirements

Documentation Required

Medical record documentation required

Rationale for testing and supporting documentation (relevant medical history, physical exam, results of prior tests/procedures, and treating physician rationale for definitive testing) must be in the medical record to support medical necessity.

Relevant medical history
Physical examination findings
Results of prior tests/procedures
Treating physician rationale for definitive testing

Billing Rule

Specimen types covered

Only urine or oral fluid specimens will be covered except blood specimens are covered for patients with anuric chronic renal failure.

Covered: urine
Covered: oral fluid
Covered (limited): blood for patients with anuric chronic renal failure

Billing Rule

Same-day duplicate testing not reimbursed

Same-day testing of the same drug or metabolites from two different samples (e.g., both blood and urine) by either presumptive or definitive analyses is not reimbursed.

Billing Rule

Multiple presumptive tests per date of service

More than one presumptive test result per patient per date of service regardless of the number of billing providers is not reimbursed; performing point-of-care and also ordering reference laboratory presumptive testing on the same specimen is not reimbursed.

80305
80306
80307

Billing Rule

Proprietary tests and large panels excluded

Orders for proprietary tests (examples listed) or definitive tests for more than seven drug classes should be expected to be denied/not reimbursed.

0328U
0082U
0051U
0054U

Denial Risk

Specimen validity testing exclusion

Specimen validity testing (urine creatinine, specific gravity, pH, oxidants, DNA identity testing) will not be reimbursed and may be denied if billed for clinical (non-forensic) outpatient drug testing.

Documentation Required

Confirmatory testing support

Confirmatory/definitive testing must be supported by documentation of rationale in the patient's medical record; the treating physician's rationale must be documented to meet coverage criteria for definitive testing.

Treating physician rationale documented in medical record

Key terms

Definitions

Presumptive drug screeningQualitative, semi-quantitative, or quantitative testing typically using immunoassay methods (commonly urine) to screen for drug classes.

Definitive/confirmatory testingLaboratory-based methods (e.g., GC-MS, LC-MS/MS) that identify specific drugs/metabolites and can provide quantitative results; coverage limited to tests of up to seven drug classes unless criteria met.

Specimen validity testingTesting to detect adulteration, dilution, or to verify sample identity (e.g., urine creatinine, specific gravity, pH, oxidants, DNA authentication); not covered for clinical outpatient testing.

Guidelines & evidence cited

Evidence: Selected guideline sources cited by the policy include the American Society of Addiction Medicine (ASAM) Appropriate Use of Drug Testing, CDC opioid prescribing guidelines, SAMHSA federal guidelines, multiple peer‑reviewed articles, and UpToDate reviews; the policy notes that these references are enumerated in the source document.

Policy review timeline

2025-02-12Last reviewLatest

Policy last reviewed

Policy Summary

Payerblue cross blue shield - tennessee

PolicyPrescription Medication and Illicit Drug Testing in the Outpatient Setting (BlueCare) – T2015

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

>90 consecutive days abstinence: definitive testing frequency 1–3 tests every three months; no more than 3 definitive tests in a three-month period

Monitoring on opioid therapy: For monitoring individuals on opioid therapy (ensure adherence, treatment planning, detection of non-prescribed opioids)

When presumptive test inadequate: When a presumptive test does not exist or does not adequately detect the specific drug or metabolite to be tested (examples listed)

Identify specific drugs or concentrations: To definitively identify specific drugs in a large family of drugs; To identify drugs when a definitive concentration is needed to guide management