Authorizations for Presumptive Urine Drug Screening Testing
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Defines prior authorization requirements, benefit limits, and clinical criteria for presumptive and definitive urine drug screening for iCare members, applicable to providers submitting PA requests for Medicare, Medicaid, and BadgerCare Plus members.
No material clinical or coverage changes in this revision.
Coverage Criteria and Thresholds
inv-01: Indication-specific coverage rules
Covered when criteria below are met for indication-specific PA requests and benefit limits:
Administrative approval by PAA; no nurse review if no prior authorization exists.
Requests authorized annually; overages reviewed for medical necessity.
Overages will deny until appropriate COT screening tool and PA with MD-signed order and notes are submitted.
Must be timely submitted.
Electronic signature acceptable; definitive testing covered as described in document.
The policy does not cover tests ordered as blanket or standing orders. Specifically, reflex definitive urine drug screening (UDS) is not reasonable and necessary when a presumptive point-of-care test has been performed and the clinician already has sufficient information to manage the patient; a clinician must place a specific, individualized order if definitive testing is required. Routine standing orders that apply to all patients in a practice are also not covered. Additionally, performing both a point-of-care presumptive test and a presumptive immunoassay (IA) from a reference laboratory for the same event is not covered — the plan will pay for only one presumptive test result per patient per date of service.
Routine reflex definitive testing by a reference laboratory following a point-of-care presumptive UDS is not covered when the clinician has sufficient information from the presumptive test to make clinical decisions. If the clinician is unsatisfied with the presumptive result, the clinician must determine clinical appropriateness and place a specific order for definitive confirmatory testing (for example, to verify an admitted use of a specific drug or when assay cut-offs make the presumptive result insufficient). Reference labs may not perform presumptive IA testing and bill for it without a specific physician order.
Covered Indications and Clinical Scenarios
inv-13: Acute clinical scenarios where DOA results may alter management
Covered when the following conditions are met for acute clinical scenarios where DOA results may alter management:
Electronic signature on the order is acceptable.
Definitive testing covered only as described in policy and will be tracked for trends; additional documentation may be requested.
See definitive ordering criteria for acceptable indications (GC-MS/LC-MS/MS, synthetic opioids, inconsistent results).
inv-14: Chronic opioid therapy (COT) monitoring and AODA/residential treatment monitoring
Covered when criteria below are met for COT monitoring and AODA/residential treatment monitoring requests:
COT screening must be completed and stored in chart; requests authorized annually; overages reviewed for medical necessity.
If UDS exceed 6, coverage will deny until an appropriate COT screening tool and a PA with MD-signed order and notes proving medical necessity are submitted.
Requests must be timely submitted within 14 days of treatment start.
Frequency Limits for Presumptive and Definitive UDS
Coding and Related Guidance
| L36037 | LCD: Urine Drug Testing (referenced pages 16-30) |
Provider Actions, Prior Authorization, and Documentation
Prior authorization: 6 benefit-level presumptive UDS authorized administratively
The initial six (6) presumptive urine drug screens per member per calendar year are authorized administratively when the provider submits the PA form; no clinical documentation or physician order is required for these six screens if the PA form is submitted within 14 days of the first UDS. Requests for more than six screens in a year must be submitted as an annual PA with supporting clinical documentation and will undergo standard PA review.
- 6 presumptive UDS authorized administratively on same authorization.
- PA form must be submitted within 14 days of the first UDS for timely administrative approval.
- Overages (>6) require annual PA with order and doctor’s note and standard review.
Reflex and step requirement: limited, circumstance-specific reflex testing only
Reflex definitive testing by reference laboratories is allowed only in specified circumstances (for example, to verify a presumptive positive using definitive methods such as GC‑MS or LC‑MS/MS or to confirm absence of a prescribed medication when lab presumptive testing is negative); blanket or routine standing reflex orders are not reasonable and necessary and are not covered.
- Reflex testing reasonable to verify a presumptive positive before reporting without an additional clinician order.
- Reflex testing reasonable to confirm absence of prescribed medication when lab presumptive UDS is negative.
- Blanket or routine reflex/standing orders for definitive testing are not allowed.
Required documentation: annual PA with clinician order and MD notes for overage/definitive testing
For requests beyond the standard six presumptive UDS per year and for definitive testing, providers must submit an annual PA that includes supporting clinical documentation: a patient‑specific clinician order, the doctor’s notes showing medical necessity, and the appropriate diagnosis on the request. Definitive testing authorizations must be patient‑specific with clinical rationale.
- Annual PA must include the amount of screens/tests requested, clinician order, and doctor's note.
- Appropriate diagnosis must be included on the request for definitive testing.
- Definitive testing must be patient‑specific with clinical rationale.
Denial triggers: overages and late definitive test submissions
Requests that exceed the six benefit‑level presumptive UDS will be denied until an appropriate COT screening tool and a PA submission that includes an MD‑signed order and clinical notes proving medical necessity are provided. Additionally, authorizations for definitive testing must be submitted within 14 days of testing or they will not be covered.
- Overage requests will deny until COT screening tool, PA, MD‑signed order, and notes demonstrating medical necessity are submitted.
- Authorizations for definitive testing must be submitted within 14 days of the test to be covered.
Ordering requirement: individualized, patient‑specific orders with clinical documentation
Orders for definitive UDS must be individualized, patient‑specific, and supported by clinical documentation (clinical rationale and appropriate diagnosis); electronic signatures on orders are acceptable. Definitive testing authorizations must be patient‑specific and include why the test was ordered.
- Orders must be individualized to the patient and include clinical rationale.
- Appropriate diagnosis must be included on the request.
- Electronic signatures on orders are acceptable.
Ordering Requirements for Definitive Testing
Ordering requirements: physician‑directed, individualized orders and timing
Physician‑directed orders are required for definitive testing; the order must be patient‑specific and include clinical documentation. Electronic signatures are acceptable and PA requests for the initial six presumptive UDS must be submitted within 14 days of the first UDS to be considered timely.
- Physician‑directed, individualized orders with clinical rationale required for definitive testing.
- Electronic signature on order is acceptable.
- Initial 6‑screen PA must be submitted within 14 days of first UDS for timeliness.
Definitions
Not Covered Services and Exclusions
The following are explicitly not covered: specimen validity testing (including pH, specific gravity, oxidants, and creatinine) and testing performed for non-clinical purposes such as employment or medico-legal reasons. Also excluded are reflex definitive testing without clinician-directed orders, blanket/standing orders, duplicate presumptive testing from reference labs, and testing of two different specimen types for the same drugs on the same date of service.
Background and Rationale
Urine drug screening (UDS) is used to support clinical management in contexts such as monitoring patients on chronic opioid therapy (COT) and members in substance use disorder/AODA treatment. The policy distinguishes between presumptive UDS — point-of-care immunoassay panels whose results must be documented in the medical record — and definitive UDS — physician-directed confirmatory testing using methods such as GC‑MS or LC‑MS/MS. Definitive testing must be individualized and ordered based on clinical history, risk, or inconsistent presumptive results; routine or reflex confirmatory testing without a clinician-directed order is not supported.
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