0054U
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical record documentation of history or suspicion of illicit/prescription drug use, documented noncompliance, or high probability of non-adherence.
- Record of the preliminary/presumptive (qualitative) test having been performed and its result.
- Documentation of a detailed discussion with the member about recent medication and drug use when used to interpret preliminary test results.
- Clinical rationale explaining why preliminary test findings are inconsistent with expectations or why drug class–specific assays are needed to identify precise drug(s); note if no reliable preliminary test exists (e.g., synthetic cannabinoids).
Key Coverage Criteria
- Outpatient confirmatory/definitive (quantitative) drug testing for a specific drug(s) when policy criteria A, B, or C are met
- Monitoring adherence to a controlled-substance treatment regimen (e.g., chronic non-cancer pain)
- Identification of drug misuse or addiction prior to initiating or during treatment with controlled substances
- Confirmatory drug/class-specific testing is medically necessary when there is a documented history or suspicion of illicit or prescription drug use, documented noncompliance, or a high probability of non-adherence to a prescribed drug regimen.
- A preliminary/presumptive (qualitative) drug test has been performed previously, unless no reliable preliminary test exists (e.g., synthetic cannabinoids).
- The preliminary/presumptive test result is inconsistent with expected results based on medical history, clinical presentation, or the member's statement after a detailed discussion about recent medication and drug use.
6 Active Policies
AMBETTER-CP.MP.50 — Drugs of Abuse: Definitive Drug Testing
BCBSIL-MED207.154 — Drug Testing in Pain Management and Substance Use Disorder Treatment
BCBSMT-MED207.154 — Drug Testing in Pain Management and Substance Use Disorder Treatment
BCBSNM-MED207.154 — Drug Testing in Pain Management and Substance Use Disorder Treatment
BCBSOK-MED207.154 — Drug Testing in Pain Management and Substance Use Disorder Treatment
Related Codes
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