Centene definitive drug testing Prior Auth

Coverage Criteria

Initial/Confirmatory Testing Criteria

Covered when ALL of the following are met under A, B, or C

A.1: A preliminary/presumptive drug test has been previously performed, unless no reliable test exists (e.g., synthetic cannabinoids).
A.2: The findings from that preliminary/presumptive (qualitative) test (either positive or negative) are either: (a) inconsistent with expected results based on medical history, clinical presentation, or member statement after detailed discussion, OR (b) consistent but drug class-specific assays are needed to identify the precise drug(s).
A.3: Resolving the inconsistency is essential to the ongoing care of the member/enrollee.
A.4: The requested confirmatory/definitive test(s) is for ≤ 14 drugs/drug classes.<=14
A.5: Tests are limited to the specific drug(s) or number of drug classes for which preliminary analysis has yielded unexpected results.

B.1: Information regarding specific substance and/or quantity is desired.
B.2: There are established benchmarks for clinical decision making based on specific substance and/or quantitative levels.
B.3: ≤ 14 drugs/drug classes are requested.<=14
B.4: Tests are limited to the specific drug(s) or number of drug classes for which the presumptive test is expected to be positive.

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

Not Medically Necessary

Considered not medically necessary when ANY of the following apply

NotMedNecessary_Group: Outpatient confirmatory/definitive (quantitative) drug testing of more than 14 drugs/drug classes; testing as a condition of employment or pre-employment; testing for participation in school or community athletic or extracurricular activities; medico-legal or court-ordered screening (unless required by state regulations); screening in asymptomatic patients except as listed in sections I or II; as part of routine physical/administrative examinations; same-day screening across specimen sources (blood, saliva, urine); blanket orders; reflex definitive drug tests when presumptive testing is performed at point of care; routine physician standing orders for all patients; billing individual definitive CPT codes when a comprehensive definitive drug testing panel is ordered; performing presumptive point-of-care testing and ordering presumptive immunoassay from a reference laboratory; performing presumptive immunoassay and ordering presumptive IA from a reference laboratory with or without reflex testing; performing IA presumptive screening prior to definitive testing without a specific physician's order; IA testing used to 'confirm' CLIA-waived presumptive methods; and specimen validity/adulteration testing (laboratory QC).>14 or administrative reasons

Medical necessity and prerequisites

Covered when policy criteria and procedural prerequisites are met as described in policy sections I., II., and III.

Presumptive testing prerequisite: A presumptive test must be performed before a definitive test unless no reliable presumptive test is in existence.

Exception added: when presumptive test is assumed positive based on history but quantitative levels are required.

Not medically necessary scenarios: Blanket orders; reflex definitive testing when presumptive testing is performed at point of care; physician standing orders for all patients; billing for individual drugs included in a billed panel; presumptive immunoassay testing in a lab when point-of-care presumptive testing has been performed; presumptive screening before definitive testing if presumptive testing was not ordered; IA testing used to confirm a presumptive POC result obtained by CLIA-waived methods.

Prior authorization rules: Prior authorization is not required for testing in children < 6 years of age; prior authorization requests will be accepted up to 10 business days after specimen collection and will be reviewed for medical necessity based on the policy criteria.10 business days

Specific exclusions from coverage include testing performed as a condition of employment or pre-employment, participation in school or community athletics or extracurricular activities, and medico-legal or court-ordered screening (unless required by state regulation). Also excluded are screening in asymptomatic patients except where specified in the policy, testing as part of routine physicals or other administrative examinations (for example, military or insurance enrollment), same-day multi-source screening across blood, saliva and urine, blanket orders, reflex definitive testing after point-of-care presumptive tests, routine standing orders for all patients, billing individual definitive CPT codes when a comprehensive definitive drug testing panel is ordered, performing presumptive point-of-care testing and then ordering presumptive immunoassay testing from a reference laboratory, and using immunoassay (IA) results to "confirm" CLIA‑waived presumptive methods. Specimen validity/adulteration testing performed solely as quality control is also excluded.

Definitive testing is intended to follow a reliable presumptive (screening) test. Ordering reflex or blanket definitive testing when a point-of-care presumptive test has already been performed, or ordering presumptive immunoassay testing from a reference laboratory when a reliable point-of-care presumptive test exists, is identified as not supporting coverage. The policy explicitly lists reflex definitive testing after POC presumptive tests and other blanket/standing order scenarios as not medically necessary.

Outpatient confirmatory/definitive quantitative drug testing that includes more than 14 drugs/drug classes is considered not medically necessary and does not meet policy criteria. The CPT descriptors for very large definitive panels (for example, CPT codes such as 0054U, 0082U, 0328U) describe testing well beyond this threshold and are listed as not supporting coverage.

The policy identifies several indications as not medically necessary, including blanket orders, reflex definitive testing when a point-of-care presumptive test was performed, routine standing orders for all patients, billing individual definitive CPTs when a comprehensive panel is ordered, and using immunoassay (IA) to "confirm" CLIA‑waived presumptive results. These scenarios, along with administrative or routine screening uses, are explicitly listed as exclusions from coverage.

Covered Indications

Confirmatory/definitive quantitative testing — covered indications

Covered indications for confirmatory quantitative testing: Confirmatory/definitive quantitative testing is covered when presumptive testing is inconsistent with clinical expectations, when specific identification or quantitation is needed to inform clinical decisions, or for serum therapeutic drug levels related to treatment.

Definitive testing coverage conditions

Definitive testing coverage: Definitive testing is covered when medical necessity criteria are met and when a presumptive test has been performed and is positive or when no reliable presumptive test exists; quantitative testing may be indicated when levels are required even if a presumptive test is assumed positive.

Coding

CPT Codes That Support Coverage CriteriaCPTCovered

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

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1/6

CPT Codes That Do Not Support Coverage CriteriaCPTNot Covered

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

HCPCS CodesHCPCS

G0480	Definitive drug test(s), qualitative or quantitative, 1 to 7 drug class(es), includes specimen validity testing.
G0481	Definitive drug test(s), qualitative or quantitative, 8 to 14 drug class(es), includes specimen validity testing.
G0659	Definitive drug test(s) performed without method or drug-specific calibration or without matrix-matched QC or without stable isotope internal standards; any number of drug classes.
G0482	Definitive drug test(s), qualitative or quantitative, 15 to 21 drug class(es), includes specimen validity testing.
G0483	Definitive drug test(s), qualitative or quantitative, 22 or more drug class(es), includes specimen validity testing.

HCPCS Codes That Support Coverage CriteriaHCPCSCovered

G0659

Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers..., qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes.

HCPCS Codes That Do Not Support Coverage CriteriaHCPCSNot Covered

G0482

Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers, (2) stable isotope or other universally recognized internal standards in all samples, and (3) method or drug-specific calibration and matrix-matched quality control material; qualitative or quantitative, all sources, includes specimen validity testing; 15 to 21 drug class(es).

G0483

Additional CPT / HCPCS codes mentioned in coding updatesmixed

80367
80368
80369
80370
80372
80373
82077
0054U
0328U
0082U

Number of drug/drug classes for outpatient definitive testing

Allowed drug/drug class countOutpatient confirmatory/definitive tests limited to ≤ 14 drugs/drug classes when policy criteria are met.

Not medically necessary thresholdOutpatient confirmatory/definitive testing of more than 14 drugs/drug classes is not medically necessary.

ApplicationLimit applies to requests under criteria A and B (presumptive test performed or expected positive) per sections I.A and I.B.

Drug class count thresholds

G0482 thresholdHCPCS G0482 describes definitive drug tests for 15 to 21 drug classes.

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for outpatient definitive/confirmatory quantitative drugs-of-abuse (DOA) testing except as noted below. Requests will be reviewed for medical necessity based on the policy criteria (e.g., documentation of history or suspicion of illicit/prescription drug use or noncompliance, and the requirements that a presumptive test was performed unless no reliable presumptive test exists, or that presumptive testing is expected to be positive and quantitative results are needed).

Prior authorization required for outpatient definitive/confirmatory quantitative DOA testing except where exempt (see timing and exemptions).
PA requests will be reviewed against the coverage criteria in Section I (A–C).
Reflex definitive testing when a point-of-care presumptive test was performed is a denial trigger (see Not Medically Necessary list).

Prior Authorization

Prior Authorization Timing & Exemptions

Testing for children under 6 years of age is exempt from prior authorization. For all other members, prior authorization requests for definitive DOA testing will be accepted up to 10 business days after specimen collection. Submitted requests received within that window will be reviewed for medical necessity against the policy criteria.

Ordering Requirements

Note

Ordering clinician responsibilities and test selection

The ordering clinician must be knowledgeable about the type of testing, the clinical indication, and test limitations; definitive testing should be ordered based on presumptive results or specific clinical need and limited to the relevant drug(s)/drug classes.

Understand testing method differences (e.g., immunoassay vs GC/MS or LC/MS)
Order definitive testing only when presumptive results or clinical circumstances justify it
Limit tests to the specific drug(s) or drug classes relevant to the clinical question

Billing Rule

Follow PA process unless exemption applies

Providers must follow prior authorization requirements except when an exemption applies (children <6); when PA is required, submit requests within the accepted post-collection window and ensure documentation meets policy criteria.

Not Covered

Certain CPT and HCPCS descriptors for very large or high-count definitive panels are identified as not supporting the policy's coverage criteria. Examples include CPT codes 0054U, 0082U, 0328U, which describe panels of 14 or more up to 120+ analytes, and HCPCS codes G0482 and G0483 that describe testing for 15–21 and 22 or more drug classes, respectively.

Tests billed under HCPCS codes G0482 (15–21 drug classes) and G0483 (22 or more drug classes) are identified as not supporting the coverage criteria and are considered not medically necessary for outpatient definitive testing per this policy. Revision history and coding updates also reflect these HCPCS codes being placed in the not‑covered group.

Definitions

Definitive/confirmatory testing

DefinitionDefinitive/confirmatory testing (e.g., GC-MS, LC-MS/MS) are laboratory methods that provide specific identification and/or quantification of drugs or metabolites with high sensitivity and specificity.

Typical methodsExamples include gas chromatography/mass spectrometry (GC/MS) and liquid chromatography with mass spectrometry (LC/MS or LC-MS/MS).

Clinical useUsed to resolve inconsistencies from presumptive testing or when precise identification/quantitation is needed to inform clinical decisions.

Immunoassay (Presumptive screening)

DefinitionImmunoassay: rapid presumptive screening tests, often point-of-care, subject to cross-reactivity and potential false positives and false negatives; not definitive.

Common use

Background

Urine (and serum) drug testing is used to monitor adherence to controlled substance therapy and to identify misuse. Initial screening is commonly performed with immunoassay point-of-care methods for rapid results, while definitive confirmatory testing (e.g., GC‑MS, LC‑MS/MS) provides specific identification and quantitation and is used when presumptive results are inconsistent with clinical expectations or when quantitative levels are required for clinical decision‑making.

Frequency Limits

FREQUENCY LIMITS — Not specified

Frequency limitsNo frequency limits specified in the policy ('Not specified').

PA timing notePrior authorization requests will be accepted up to 10 business days after specimen collection (operational protocol).

ExemptionTesting for children < 6 years of age is exempt from prior authorization (related operational note).

FREQUENCY LIMITS — (no summary provided)

Frequency limits (no summary)No summary provided in the brief; frequency not otherwise specified in policy windows reviewed.

Policy review notePolicy updated annually per revision history; no frequency constraints added in recent updates.

Revision History

06/21coding update

Annual review with references updated and coding reviewed; added 2021 CPT 82077 to list of codes that support coverage criteria and adjusted header review date language.

03/23coding update

Annual review; added CPT 0082U to the CPT codes that do not support coverage criteria and removed deleted CPT codes 0143U–0150U from lists.

06/23coding update

Removed deleted CPT codes 0143U–0150U from the CPT codes that do not support coverage criteria during a coding table update.

OpenPayer

Drugs of Abuse: Definitive (Confirmatory) Testing