MEDICAL POLICY
For use with the UnitedHealthcare Laboratory Benefit Management Program, administered by BeaconLBS
DRUG TESTING
Policy Number: CMP - 029
Effective Date: June 18, 2016
Table of Contents
BACKGROUND
POLICY
REFERENCES
POLICY HISTORY/REVISION HISTORY
Page
1
4
6
6
INSTRUCTIONS FOR USE
This Medical Policy provides assistance in interpreting UnitedHealthcare benefit plans. When deciding
coverage, the enrollee specific document must be referenced. The terms of an enrollee's document (e.g.,
Certificate of Coverage (COC) or Summary Plan Description (SPD)) may differ greatly. In the event of a
conflict, the enrollee's specific benefit document supersedes this Medical Policy. All reviewers must first
identify enrollee eligibility, any federal or state regulatory requirements and the plan benefit coverage prior
to use of this Medical Policy. Other Policies and Coverage Determination Guidelines may apply.
UnitedHealthcare reserves the right, in its sole discretion, to modify its Policies and Guidelines as necessary.
This Medical Policy is provided for informational purposes. It does not constitute medical advice.
UnitedHealthcare may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist
us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the
independent professional medical judgment of a qualified health care provider and do not constitute the
practice of medicine or medical advice.
BACKGROUND
Drug abuse is a growing problem in the United States. In 2008, there were 36,450 deaths from overdose in the
United States, with prescription drugs causing 74%1. Death from opioid pain relievers increased four-fold over
the period from 1999-2008, and these overdoses accounted for more deaths from overdose than heroin and
cocaine combined. Just under a million Americans use heroin, and 3.6 million regularly use cocaine.2
Qualitative drug testing in most cases refers to urine tests. Urine testing can include validity testing measures
including creatinine, urine specific gravity, pH, and detection of additives. A sensitive test, the immunoassay, is
usually the first assay for the initial evaluation, and it detects the presence of certain selected classes of drugs.
Then, if the test is positive and there is a need for specific identification of a drug, gas chromatography/mass
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spectroscopy (GC/MS) can confirm results, reduce false positives and false negatives, and give a specific
identification. This assay is the standard in forensic testing.
The use of presumptive qualitative versus definitive quantitative confirmation3 depends on whether or not
there is a medical necessity to obtain the exact concentration of the drug or its metabolite in the specimen.
Proper documentation by the ordering provider (physician) will include the medical necessity in the order.
For qualitative drug tests, proper documentation is needed when the testing exceeds 12 per calendar year. For
example, patients suffering from substance abuse disorder (SUD) can have excessive qualitative tests done not
exceeding 3 times within a seven day period.
Quantitative testing is usually done:
 To support a patient’s ongoing use or discontinuation of a specific drug.
 To confirm the screening result identifying the analyte causing a positive reaction or to ensure
that the patient is truly negative for a drug.
Quantitative tests also require proper documentation4. This documentation is needed for example when testing
exceeds 12 definitive tests per calendar year (~1-3 times every 3 months)3.
Limitations to initial testing with immunoassays include cross-reactivity and failure to detect structural diversity
within a class. According to recommendations made for the use of laboratory testing for poisoned patients
presenting to the emergency department, cross-reacting substances should be listed when a positive result is
reported.4 Examples of some cross-reactive substances include poppy seeds (causes false positive for morphine)
and Zoloft (causes false positives for benzodiazepines). Clonazepam and lorazepam can produce false-negative
results. Due to drug metabolism, immunoassay cannot distinguish between morphine, codeine, and heroin.
Semi-synthetic and synthetic opioids such as oxycodone and fentanyl may not be detected by standard
immunoassays, but specific enzyme immunoassays are available for these drugs.
Qualitative drug tests do not screen for drug use in the strict sense of the word because the initial assay used
does not detect all drugs. The actual tests performed and the drugs that are screened differ depending on the
setting, as does the need for confirmatory testing. Screening cutoff concentrations vary depending on the
context. Qualitative drug testing serves different purposes in a variety of settings. The testing can be used to
screen for drug use in the emergency department and the workplace. In settings where drug use is the norm,
such as pain clinics and psychiatric units, the tests can be used to establish compliance and detect prescription
abuse. Medico legal drug testing follows forensic protocols, where chain of custody is an issue.
In the emergency department, drug testing is often done to guide clinical care for unstable patients who, due to
conditions such as drowsiness or seizure, may not provide a history. In this setting, the clinician is often
attempting to ascertain if drug toxicity can explain the patient’s symptoms, and if so, to identify the drug(s).
Fast turnaround times are essential to the utility of the assay. Drugs tested in the emergency department
include drugs of high abuse potential such as cocaine, amphetamines, methamphetamines, barbiturates,
benzodiazepines, heroin, and methadone. According to recommendations written for emergency department
laboratory tests, drug testing panels should not be based on toxidromes (a collection of signs and symptoms
characteristic of use of a particular drug class) because this practice introduces a potential for misdiagnosis.4
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These recommendations state that “stat” qualitative urine toxicology assays supporting an emergency
department should detect cocaine, opiates, barbiturates, amphetamines, propoxyphene, phencyclidine, and
tricyclic antidepressants. Test results for selected drug classes are reported as positive or negative. Drug testing
in the emergency department has fallen under criticism due to concerns of cost and low impact on treatment.
Testing for acetaminophen toxicity, which is a separate serum quantitative test, is largely immune to this
scrutiny because there is a specific antidote (N-acetylcysteine) that can prevent fulminant hepatic failure when
used early in the course of the overdose. The National Academy of Clinical Biochemistry has stated that if
recommendations were made to deter use of qualitative urine drug screening, it is unlikely that emergency
departments would change their use of the tests.4 While qualitative drug tests continue to be used frequently in
the emergency department, cost and turnaround time for confirmatory testing with GC/MS may preclude its
overall utility in this setting.
Controlled prescription drugs are commonly prescribed in outpatient pain clinics, and this setting is often the
site of prescription fraud and abuse. Chronic non-cancer pain patients are at the highest risk to abuse controlled
substances compared to all other patient populations who undergo urine drug testing.5 Medicaid populations
are at a higher risk for death from opioid pain relievers than their non-Medicaid counterparts. Comorbid
substance use disorders are common in patients treated for chronic pain.6 Clinicians who treat patients with
chronic pain need to know if the patient is taking the drugs as prescribed or if the patient has been stockpiling
drugs for later diversion to the criminal market, a practice that is estimated to cost insurance companies $72.5
billion annually in healthcare costs. Although there is no evidence-based literature for the practice,7 in the
chronic pain clinic, urinary drug testing is the test of choice for adherence monitoring. Urine drug tests can
provide caregivers with results that are important to monitor and safeguard their prescribing practices. The
results of the tests for any one patient can lead to several possible conclusions7:
1. The patient is taking the drugs as prescribed because testing is positive for the prescribed drugs
and negative for other drugs.
2. The patient is diverting prescription drugs to the illicit marketplace because the patient tests
negative for the prescribed opioid.
3. The patient abuses controlled substances because there are positive results for the prescribed drug
and for other non-prescribed opioids or benzodiazepines.
4. The patient has a comorbid substance use disorder because the test detected street narcotics.
5. The patient is likely abusing the system due to results that indicate specimen tampering.
A new local carrier determination that was issued in 2009 has curtailed monitoring of chronic pain patients in the
outpatient setting. Subsequently, in some regions, qualitative drug tests are only covered if the patient’s
behavior suggests illicit drug use. Yet studies have shown that clinicians cannot predict drug abuse based on
patient behavior.2, 5
One multicenter study of patients receiving long-term opioid therapy found that 72% of patients with urine drug
tests indicative of potential addiction or drug diversion did not display behaviors that would suggest deviance.5
Behaviors that are suggestive of inappropriate drug use include lost or stolen prescriptions, consumption of
drugs in excess of prescribed amount, reporting multiple drug allergies, making office visits without
appointments, and calling the clinic frequently.2
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In the workplace qualitative drug tests are often used as part of a pre-employment screen and as a means to
ensure peak employee performance. Other circumstances for testing include suspicion of drug use and accident
investigation.
The Department of Health and Human Services guidelines authorize testing of federal employees for
amphetamines, cannabinoids, cocaine, opiates, and phencyclidine.8
To avoid false positives, cutoff values in the workplace are generally set higher than clinical cutoffs used in
emergency departments.4 Positive results usually indicate drug use within the past one to three days, with
marijuana the exception. It can be detected weeks after heavy use. Tests for specimen adulteration are
important in this setting.
Point of care testing, while offering convenience, has not been universally accepted for drug testing. The
National Academy of Clinical Biochemistry (NACB) guidelines for point of care testing state there is no evidence
base for the use of point of care testing in pain clinics. Due to lack of evidence from outcome studies, the NACB
guidelines state that point of care testing in the emergency department has controversial value9. These tests
generally have a higher unit cost than qualitative drug tests performed by a central laboratory.
POLICY
For the following CPT code(s) in Table 1 and 2, the patient should have a diagnosis (ICD-10-CM) code(s) listed in
the attached files below.
Table 1. HCPCS Group 1 (presumptive) Codes (Alphanumeric, CPT AMA)
Code
G0477
Description
Drug tests(s), presumptive, any number of drug classes; any number of devices or
procedures, (eg, immunoassay) capable of being read by direct optical
observation only (eg, dipsticks, cups, cards, cartridges), includes sample validation
when performed, per date of service.
G0478
Drug tests(s), presumptive, any number of drug classes; any number of devices or
procedures, (eg, immunoassay) read by instrument-assisted direct optical
observation (eg, dipsticks, cups, cards, cartridges), includes sample validation
when performed, per date of service.
Drug tests(s), presumptive, any number of drug classes; any number of devices or
procedures by instrumented chemistry analyzers (eg, immunoassay, enzyme
assay, TOF, MALDI, LDTD, DESI, DART, GHPC, GC mass spectrometry), includes
sample validation when performed, per date of service.
G0479
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Table 2. CPT and HCPCS Group 2 (definitive) Codes (Alphanumeric, CPT AMA)
Code
80159
Drug assay clozapine
80171
Drug screen quantitative gabapentin
80173
Drug screen quantitative halopridol
80183
Drug screen quantitative oxcarbazepine
80184
Drug screen quantitative phenobarbital
83992
Assay of phencyclidine
G0480
Drug test(s), definitive, utilizing drug identification methods able to identify individual
drugs and distinguish between structural isomers (but not necessarily stereoisomers),
including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type,
single or tandem and excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and
enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all
sources, includes specimen validity testing, per day, 1-7 drug class(es), including
metabolite(s) if performed
Drug test(s), definitive, utilizing drug identification methods able to identify individual
drugs and distinguish between structural isomers (but not necessarily stereoisomers),
including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type,
single or tandem and excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and
enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all
sources, includes specimen validity testing, per day, 8-14 drug class(es), including
metabolite(s) if performed.
G0481
Description
G0482
Drug test(s), definitive, utilizing drug identification methods able to identify individual
drugs and distinguish between structural isomers (but not necessarily stereoisomers),
including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type,
single or tandem and excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and
enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all
sources, includes specimen validity testing, per day, 15-21 drug class(es), including
metabolite(s) if performed.)
G0483
Drug test(s), definitive, utilizing drug identification methods able to identify individual
drugs and distinguish between structural isomers (but not necessarily stereoisomers),
including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type,
single or tandem and excluding immunoassays (eg, IA, EIA, ELISA, EMIT, FPIA) and
enzymatic methods (eg, alcohol dehydrogenase)); qualitative or quantitative, all
sources, includes specimen validity testing, per day, 22 or more drug class(es), including
metabolite(s) if performed
Group1 ICD-10 Diagnosis Codes (Proven)
CMP-029 Drug
Testing ICD10 Grp1
Group2 ICD-10 Diagnosis Codes (Proven)
CMP-029 Drug
Testing ICD10 Grp2
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REFERENCES
1.
Centers for Disease Control and Prevention. Vital signs: overdoses of prescription opioid pain relievers—
United States, 1999-2008. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487-1492.
2.
Katz NP,Sherburne S,Beach M, et al. Behavioral monitoring and urine toxicology testing in patients
receiving long-term opioid therapy. Anesth. Analg. 2003;97(4):1097-1102.
3.
Novitas Solutions. Local Coverage Determination (LCD) L35006 Controlled Substance Monitoring and
Drugs of Abuse Testing. Effective 12/31//15.
4.
Wu AHB,McKay C,Broussard LA, et al. National academy of clinical biochemistry laboratory medicine
practice guidelines: recommendations for the use of laboratory tests to support poisoned patients who
present to the emergency department. Clin. Chem. 2003;49(3):357-379.
5.
Gilbert JW,Wheeler GR,Mick GE, et al. Urine drug testing in the treatment of chronic noncancer pain in a
Kentucky private neuroscience practice: the potential effect of Medicare benefit changes in Kentucky.
Pain physician. 2010;13(2):187-194.
6.
Morasco BJ,Gritzner S,Lewis L, et al. Systematic review of prevalence, correlates, and treatment
outcomes for chronic non-cancer pain in patients with comorbid substance use disorder. Pain.
2011;152(3):488-497.
7.
Christo PJ,Manchikanti L,Ruan X, et al. Urine drug testing in chronic pain. Pain physician. 2011;14(2):123143.
8.
Department of Health and Human Services Substance Abuse and Mental Health Services Administration.
Mandatory guidelines for federal workplace drug testing programsnotice November 25 Fed Regist.
2008;73(228 ):71857-71907.
9.
Nichols JH, Christenson RH, Clarke W, et al. National Academy of Clinical Biochemistry Laboratory
Medicine Practice Guidelines: Evidence Based Practice for Point of Care Testing. AACC Press; 2006.
POLICY HISTORY/REVISION HISTORY
Date
06/18/2016
Action/Description
Revised policy CPT/HCPCS codes and ICD10 codes to reflect Novitas’ LCD Policy
#35006 “Controlled Substance Monitoring and Drugs of Abuse Testing”.
12/03/2015
Annual Policy Review Completed – no changes.
10/01/2015
Removed ICD9 table. Embedded ICD9/ ICD10 PDF files.
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