Drugs of Abuse: Definitive Drug Testing

This policy covers outpatient confirmatory/definitive (quantitative) drug testing—including GC‑MS/LC‑MS/MS identification of specific drugs/metabolites and serum therapeutic drug level testing—when medically necessary. It applies to patients monitored on controlled‑substance regimens (e.g., chronic non‑cancer pain), those suspected of misuse/addiction, or when a preliminary/presumptive test is inconsistent or insufficient (children <6 exempt from prior authorization), but requires a reliable preliminary test unless none exists, is limited to the specific drugs/drug classes identified and to ≤14 drugs/classes, and excludes routine/employment/school/medico‑legal screenings, blanket or reflexive orders, and same‑day redundant testing.

"Outpatient confirmatory/definitive (quantitative) drug testing for a specific drug(s) when policy criteria A, B, or C are met"

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