CurrentCignaPolicy 0513

Clinical drug testing (presumptive and definitive)

Cigna Medical Coverage Policy 0513 defines medical necessity, coverage limits, specimen/source and testing methodology guidance for presumptive (screening) and definitive (confirmatory) drug testing for addiction treatment and monitoring, including coding and reimbursement rules and excluded methods.

Policy Summary

PayerCigna

PolicyClinical drug testing (presumptive and definitive)

Policy CodePolicy 0513

Change TypeAnnual & Focused reviews (revisions and removals)

Effective DateFeb 15, 2025

Next Review DateFeb 15, 2026

Key ActionDocument clinical rationale in the medical record and ensure tests billed meet one-test-per-date limits and methodologic/quality control requirements.

SourceLink

POLICY UPDATE CHANGES

Removed policy statement for CLIA approved laboratories.

Revised policy statements for presumptive and definitive drug testing.

Added policy statements regarding testing limits on presumptive and definitive drug testing.

Removed the not medically necessary policy statement for additional testing to determine drug misuse.

Removed annual limits for drug testing.

1Presumptive tests allowed per date of service

1Definitive G0480/G0659 tests allowed per date of service

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Coverage Summary

This policy (Medical Coverage Policy 0513) addresses clinical drug testing for addiction treatment, covering both presumptive (screening) and definitive (confirmatory) testing and providing coding, reimbursement rules, specimen/source and methodology guidance. The policy stance is mixed: certain presumptive and definitive tests are considered medically necessary when criteria are met, while specific methods and tests are not covered. Effective date: 2/15/2025. Next review date: 2/15/2026.

Surface thresholds and quick facts

Effective date2025-02-15

Next review date2026-02-15

Presumptive tests allowed per date of service1 per date of service (no more than one)

Definitive G0480/G0659 tests allowed per date of service1 per date of service (no more than one)

Definitive testing per day drug classes threshold (not covered group)22 or more drug class(es) per day (HCPCS G0483)

Hair analysis coverageNot covered / not reimbursable (CPT/HCPCS P2031)

Definitive HCPCS codes explicitly not coveredG0481, G0482, G0483 are not covered or reimbursable

Medical-Necessity Criteria

Presumptive (Screening) Drug Testing - Medically Necessary

Presumptive drug testing not to exceed one test per date of service is considered medically necessary when the following are met:

ALL of the following

There is a suspicion of drug misuse by the individual being tested
Testing is presumptive (qualitative) using appropriate methods (eg, dipsticks, cups, cards, cartridges, instrumented immunoassays)
No more than one presumptive test is billed per date of service
Services in excess of one test per date of service are not covered or reimbursable

Definitive (Confirmatory) Drug Testing - Medically Necessary (G0480 or G0659)

Definitive drug testing not to exceed one test per date of service using specified HCPCS codes is considered medically necessary when the following are met:

Not Covered / Not Reimbursable

Not Covered / Not Reimbursable Codes - Hair Analysis

Hair analysis not covered: Hair analysis (excluding arsenic) is not covered or reimbursable (CPT/HCPCS P2031)

Associated code: P2031

Coding

Presumptive CPT 80305-80307CPTCovered

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.

Definitive HCPCS G0480,G0659HCPCSCovered

G0480	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.
G0659	Drug test(s), definitive, utilizing drug identification methods... performed without method or drug-specific calibration, without matrix-matched QC, or without use of stable isotope/internal standard(s); qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes.

Definitive HCPCS G0481-G0483HCPCSNot Covered

G0481	Definitive test, includes specimen validity testing, per day, 8-14 drug class(es).
G0482	Definitive test, includes specimen validity testing, per day, 15-21 drug class(es).
G0483	Definitive test, includes specimen validity testing, per day, 22 or more drug class(es).

P2031 hair analysisHCPCS|CPTNot Covered

P2031

Hair analysis (excluding arsenic)

descriptive/methodsmixed

No codes listed

Provider Actions & Billing Rules

Documentation Required

Clinical documentation requirement

Clinical records must document diagnosis, history and physical exam and/or behavior supporting testing for specific drug(s)/substance(s) and document how test results will impact treatment planning.

Billing Rule

One test per date of service limit

Presumptive testing and definitive testing using G0480 or G0659 are reimbursable up to one test per date of service; services in excess of one test per date of service are not covered or reimbursable. Affected codes: 80305, 80306, 80307, G0480, G0659.

80305
80306
80307

Background, Evidence & Definitions

Drug testing is used as a diagnostic and therapeutic tool in addiction treatment and may be performed as presumptive (qualitative) screening or definitive (chromatography/mass spectrometry) confirmatory testing. Presumptive tests are qualitative immunoassays or similar methods (eg, dipsticks, cups, cards, cartridges, instrumented immunoassays) and are typically read visually or by instrument. Definitive testing uses chromatography and mass spectrometry methods (eg, GC/MS, LC/MS) that identify and often quantify drugs/metabolites and distinguish structural isomers and are higher-complexity methods. Specimen verification and validity testing (eg, creatinine, pH, specific gravity, adulterants) are considered part of quality assurance and are included in test codes; they are not separately reimbursable. CLIA considerations: high-complexity definitive testing should be performed in a CLIA-accredited laboratory to ensure quality control and trained personnel, while many point-of-care tests are CLIA-waived and have different validation standards. Testing frequency should be guided by clinical risk, treatment phase and clinical utility — generally more frequent at treatment initiation and decreased as stability/abstinence is achieved — with presumptive and definitive testing ordered when results will impact treatment planning.

source label	summary
SAMHSA (2012)
Notes limitations of hair testing and specimen validity parameters; recommends confirmatory testing practices and discusses specimen validity testing methods (creatinine, pH, specific gravity, adulterants).

term	definition
Presumptive testing
Qualitative analysis to determine whether a specific drug/drug metabolite/substance is detectable above a threshold concentration (eg, immunoassays, dipsticks, cups); results read by direct optical observation with or without instrument assistance.
Definitive testing
Methods that identify and often quantify drugs/metabolites (eg, GC/MS, LC/MS) and distinguish structural isomers; higher-complexity testing typically performed in CLIA-accredited labs and used when results will inform clinical decisions.
Specimen verification
Assessment of specimen integrity (eg, creatinine, pH, specific gravity, adulterants); considered part of quality assurance and not separately reimbursable.
Definitive/Confirmatory/Quantitative testing
Analytical methods that identify individual drugs and distinguish structural isomers (eg, GC/MS, LC/MS), require stable isotope/internal standards, method- or drug-specific calibration and matrix-matched QC; excludes immunoassays and enzymatic methods.

Medicare Determinations

type	number	name	effective date
LCD
L36393
Controlled Substance Monitoring and Drugs of Abuse Testing (L36393)
2019-10-01
LCD
L35006
Controlled Substance Monitoring and Drugs of Abuse Testing (L35006)
2019-10-17
NCD

No National Coverage Determination found

Revision History

2023-12-03added

Added policy statements regarding testing limits on presumptive and definitive drug testing; removed previous not medically necessary statement for additional testing to determine drug misuse.

2024-01-15removed

Removed annual limits for drug testing.

2025-02-15revised/removedLatest