CurrentCentenePolicy N/A

Drugs of Abuse: Definitive Testing

Coverage and medical necessity criteria for definitive (confirmatory) testing for drugs of abuse for Centene-affiliated health plans; addresses coding, prior authorization protocols, and clinical rationale. Affects providers ordering definitive drug testing and billing for such tests.

Policy Summary

PayerCentene

PolicyDrugs of Abuse: Definitive Testing

Policy CodePolicy N/A

Change TypeCoding, coverage and authorization updates

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests within 10 business days post-collection; note that HCPCS codes G0482 and G0483 are not medically necessary and may be denied.

SourceLink

POLICY UPDATE CHANGES

Revised policy to state that HCPCS codes G0482 & G0483 are not medically necessary, and to reflect a 10 day post-collection authorization period.

Removed presumptive drug testing criteria from this policy and created a separate presumptive testing policy (CP.MP.208); removed presumptive testing codes 80305, 80306, 80307.

Added multiple CPT and HCPCS codes to coding tables and marked specific CPT codes as not supporting coverage criteria (e.g., 0143U-0150U; later removed when deleted), and added/removed other codes across updates.

Revised wording in I.A.1 from 'unless no reliable test is available' to 'unless no reliable test is in existence'.

Policy name changed from 'Outpatient Testing for Drugs of Abuse' to 'Drugs of Abuse: Definitive Testing' and presumptive testing limits removed.

35presumptive tests allowed (KY note)

16definitive tests allowed (KY note)

10 dayspost-collection auth window

Policy Summary

PayerCentene

PolicyDrugs of Abuse: Definitive Testing

Policy CodePolicy N/A

Change TypeCoding, coverage and authorization updates

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests within 10 business days post-collection; note that HCPCS codes G0482 and G0483 are not medically necessary and may be denied.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage and Medical Necessity Criteria

Definitive testing coverage overview

Covered when medical necessity criteria in policy are met; definitive testing is governed by this policy and is separated from presumptive testing (see CP.MP.208).

Policy-level coverage determination: Definitive testing is governed by this policy with criteria; presumptive testing criteria were removed to CP.MP.208

Full node-level criteria (I.A.1 etc.) are referenced in the policy; providers must meet the medical necessity criteria described in the policy for coverage.

Definitive (confirmatory) drug testing is covered when the policy's medical necessity criteria are met. This policy addresses laboratory-based definitive assays (for example, GC/MS or LC-MS/MS) used to confirm suspected drug exposure and to monitor patients in chronic pain or addiction care settings. Note that presumptive testing criteria have been removed from this document and are addressed in a separate policy (CP.MP.208), so reflexive ordering of definitive tests following point-of-care presumptive testing is treated as an exclusion unless specific medical necessity criteria are met.

The policy identifies HCPCS codes G0482 and G0483 as not medically necessary. Use of these HCPCS codes may trigger a claim denial when billed for definitive drug testing.

Not medically necessary indications specifically include blanket orders or standing orders that apply to all patients; reflexive definitive testing performed after a CLIA-waived point-of-care presumptive test (i.e., ordering definitive testing solely because a POC presumptive screen was done); and physician standing orders applied to all patients regardless of individual clinical rationale. Billing for individual drugs that are included as part of a billed panel is also listed among not medically necessary situations.

When Definitive Testing Is Covered

Monitoring in chronic pain and addiction medicine contexts

Definitive drug testing may be covered for monitoring and confirmation in chronic pain and addiction medicine when clinically indicated and supported by standards of practice and cited guidance.

Coverage for monitoring and confirmation

Standards and guidance: Appropriate use should be consistent with referenced guidance such as ASAM, SAMHSA Treatment Improvement Protocols, CDC opioid prescribing guidance, and clinical reviews (see policy references).
References include Becker & Starrels, SAMHSA TIP 47, CDC 2016 opioid guideline, UpToDate reviews and other literature cited in the policy.
Clinical indication requirement: There must be a documented clinical indication (e.g., monitoring prescribed controlled substances, suspected unreported or illicit drug use, confirmation of presumptive positive results when clinically appropriate).
Definitive testing (e.g., GC/MS, LC-MS/MS) is the laboratory confirmatory method; presumptive testing guidance has been moved to CP.MP.208.

Code Tables and Related Coding Information

Coding updates and notable code statusmixed

80367	listed in updated coding tables
80368	listed in updated coding tables
80369	listed in updated coding tables
80370	listed in updated coding tables; description updated in 03/22 review
80372	listed in updated coding tables
80373	listed in updated coding tables
0143U	added as CPT code not medically necessary (later removed when deleted)
0144U	added as CPT code not medically necessary (later removed when deleted)
0145U	added as CPT code not medically necessary (later removed when deleted)
0146U	added as CPT code not medically necessary (later removed when deleted)

1–10 of 22

1/3

HCPCS codes identified as not medically necessaryHCPCSNot Covered

G0482	identified as not medically necessary
G0483	identified as not medically necessary

ICD-10-CM codes and ranges referencedICD-10

F13.19	Sedative, hypnotic or anxiolytic-related dependence
F55.0	Abuse of antacids
F55.1	Abuse of herbal or folk remedies
F55.2	Abuse of laxatives
F55.3	Abuse of steroids or hormones
F55.4	Abuse of vitamins
F55.8	Abuse of other non-psychoactive substances
Z79.891	Long term (current) use of opiate analgesic (adjusted from Z79.81)

Presumptive and definitive test counts (KY-specific)

KY-specific test count allowanceUp to 35 presumptive tests and up to 16 definitive (confirmatory) tests are allowed without prior authorization for the WC of KY modification.

Scope of allowanceThis KY modification specifies counts for tests permitted without authorization; it applies to the modified WC of KY health plan language in the policy.

Effect on prior authorizationTests within these counts do not require submission of prior authorization per the KY-specific modification; requests beyond these counts follow standard PA rules.

Prior Authorization, Billing, and Provider Requirements

Prior Authorization

Prior Authorization Required

Prior authorization timing and pediatric exemption. Prior authorization requests for definitive drug testing will be accepted up to 10 business days after specimen collection and will be reviewed for medical necessity. Testing for children under 6 years of age is exempt from prior authorization.

PA requests accepted up to 10 business days post-specimen collection
Requests reviewed for medical necessity based on policy criteria
Children < 6 years — exempt from prior authorization

Billing Rule

Billing Rule / Denial Risk

Billing and denial risk: HCPCS codes G0482 & G0483. Use of HCPCS codes G0482 and G0483 for definitive drug testing is identified as not medically necessary and may trigger claim denial if billed.

Ordering, Authorization, and Special Rules

Note

Ordering requirements and pediatric PA exemption

Per revised ordering protocols, testing for children under 6 years of age is exempt from prior authorization in the noted protocol additions; follow the stated prior authorization timelines and procedures where applicable.

Children <6: PA not required per the added protocol language.
Follow PA protocol: requests accepted up to 10 business days after specimen collection and reviewed for medical necessity.

Frequency and Limits

FREQUENCY LIMITS — Presumptive testing

Previous inclusion then removalPresumptive testing limits for chronic opioid therapy were added to this definitive testing policy and later removed; presumptive testing criteria were moved to separate policy CP.MP.208.

Codes removed with movePresumptive CPT codes 80305, 80306, and 80307 were removed from this policy when presumptive testing was relocated to CP.MP.208.

Resulting policy organizationDefinitive testing criteria remain in this policy while presumptive testing frequency rules and related codes are maintained in CP.MP.208 (Drugs of Abuse: Presumptive Testing).

Key Definitions

DEFINITIVE TESTING — Definition

Definition of definitive (confirmatory) testingDefinitive (confirmatory) testing is laboratory-based analytic testing (e.g., GC/MS, LC-MS/MS) used to confirm presumptive positive results.

Policy separation notePresumptive testing criteria and codes were removed from this definitive testing policy and placed into a separate presumptive testing policy (CP.MP.208).

Examples of definitive methodsDocument cites GC/MS and LC-MS/MS as examples of laboratory-based analytic methods used for definitive confirmation.

Exclusions and Not Medically Necessary Services

This policy states that certain testing scenarios are not covered: presumptive immunoassay testing performed in a laboratory when a CLIA-waived point-of-care presumptive test has already been performed, blanket or standing-order testing arrangements, reflexive confirmatory testing initiated solely because a POC presumptive test was done, and use of certain CPT/HCPCS codes flagged as not supporting coverage. These not-covered indications have been added and revised across multiple updates to the policy.

Clinical Rationale and References

Clinical rationale for definitive (confirmatory) drug testing is informed by standards of practice and guideline sources cited in the policy, including guidance relevant to chronic pain and addiction medicine. The policy references professional guidance and literature (for example, ASAM, SAMHSA, CDC and clinical reviews) to support the role of laboratory-based definitive testing for confirmation of suspected drug exposure and for monitoring when clinically indicated.