Urine Drug Testing

Covered: Presumptive and definitive urine drug testing (including direct-to-definitive and laboratory reflex confirmation by GC‑MS/LC‑MS/MS) are covered for emergent symptomatic evaluation (Group A), SUD diagnosis/treatment and monitoring including random testing (Group B), and baseline/monitoring of chronic opioid therapy (Group C); excluded are UDT for medico‑legal/employment purposes, separate billing for specimen‑validity tests, duplicate same‑day different‑specimen testing for the same analytes, and immunoassay (IA) results are never considered confirmatory. Key requirements: clinician order and medical‑necessity documentation (individualized rationale, risk assessment, history, documented COT risk category, and adherence to specified frequency limits by abstinence duration and COT risk) are required for coverage, and definitive testing must be justified and documented when used to confirm unexpected presumptive results.

"Group A – Symptomatic patients, multiple drug ingestion and/or patients with unreliable history: Presumptive UDT performed as part of evaluation and management of a patient who presents in an emerg..."