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Rural Carrier Benefit Plan
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Urine Drug Testing Coverage

Urine drug testing/screening, when conducted for medical purposes related to the evaluation of patients being treated with controlled substances for non-cancer-related chronic pain, is covered only as described below.

These requirements do not apply when urine drug testing/screening is performed:

  • as part of an emergency room or urgent care center visit
  • during an observation or inpatient hospital stay
  • in an outpatient facility setting such as a hospital or an ambulatory surgical center.
  • Documentation requirements prior to performing urine drug testing/screening and any confirmatory testing:

Servicing providers (if not the requesting provider) performing any urine drug tests/screenings must secure, from an authorized requesting provider, a legibly signed, written request/order, dated on the date the urine specimen is collected, that is specific to the Plan member being tested. Tests performed pursuant to orders/requests for pre-selected tests or panels of tests applicable to multiple patients are not covered. The patient specific request/order must specify the following:

  • Drugs to be screened
  • Specific reason for testing – e.g., new patient, initiation of new controlled substance therapy, compliance monitoring (scheduled or random), or unexpected result/complaint/behavior pattern (describe circumstance)
  • Specific diagnosis for which testing is being requested
  • Confirmatory testing to be performed
  • Type of adulteration testing requested

A copy of the request/order must be provided to the Plan with any claim requesting reimbursement for urine drug testing. If claim is submitted by requesting provider for urine drug testing/screening (POC testing), specific diagnosis and reason for testing must be described in patient’s medical record. Such requested/ordered testing will be covered by the Plan only if the following requirements are met:

Qualitative testing, whether point-of-care (POC) (by requesting provider) or other servicing provider-based (e.g., laboratory), for urine drug screening is covered only for:

  • New patients – baseline
  • Patients starting on new controlled substance – baseline
  • Compliance monitoring within 1-3 months post baseline test
  • Random monitoring thereafter approximately every 6-12 months
  • Monitoring for unexpected results, complaints, or behavior patterns (basis for such testing must be documented in patient’s medical record; if test is billed by servicing provider, supporting medical record submission is responsibility of servicing provider)
  • Services appropriately billed pursuant to current Medicare guidelines under HCPCS Codes G0477- G0483

Confirmatory, qualitative or quantitative, urine drug testing is covered only for:

  • Positive results from covered qualitative tests
  • Unexpected negative results from covered qualitative tests (basis for classification as unexpected negative test result must be documented in patient’s medical record; if test is billed by servicing provider, supporting medical record submission is responsibility of servicing provider)
  • Services appropriately billed pursuant to current CPT guidelines under CPT Codes 80375-80377 or CPT Chemistry section or CPT Therapeutic Drug Assay section (or their successor sections)
  • Test units deemed by the Plan to be medically necessary and appropriate (basis for multiple test units must be documented in patient’s medical record; if test is billed by servicing provider, supporting medical record submission is responsibility of servicing provider)
  • Qualitative confirmation (CPTs 80375-80377 or other applicable CPT Code) and a quantification of the same drug by another method (e.g., GC/MS) will not be considered medically necessary unless conflicting results are obtained for initial qualitative screen and the qualitative confirmation test
  • Results of all initial qualitative tests/screenings performed must be supplied with billings for confirmatory tests

The following additional tests may also be considered appropriate to verify that a urine sample was not adulterated when specifically ordered by the authorized requesting provider:

  • CPT 81002 – urinalysis non-automated, without microscopy
  • CPT 81003 – urinalysis automated, without microscopy
  • CPT 82570 – creatinine; other source