80184
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
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
- Presumptiveurine drug testing (UDT) to verify compliance with treatment, identify undisclosed drug use or abuse, or evaluate aberrant* behavior, is consideredmedically necessary, beginning at the start of treatment, as part of a monitoring program tailored to the unique needs of individuals who are:
- Receiving treatment for chronic pain with prescription opioid or other potentially abused medications;or
- Undergoing treatment for, or monitoring for relapse of, opioid or other substance use disorder.
- Presumptiveurine drug testing is also consideredmedically necessaryfor the following:
- To assess an individual when clinical evaluation suggests use of non-prescribed medications or illegal substances;or
- On initial entrance into a pain management program or substance use disorder recovery program.
2 Active Policies
AMBETTER-CP.MP.50 — Drugs of Abuse: Definitive Drug Testing
ANTHEM-CG-LAB-09 — CG-LAB-09 Drug Testing or Screening in the Context of Substance Use Disorder and Chronic Pain
Related Codes
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