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This policy addresses urine drug testing in patients with chronic non-cancer pain who are on chronic opioid therapy. Chronic non-cancer pain is pain in which the causes cannot be removed or otherwise treated and no relief or cure has been found after reasonable efforts. Chronic opioid therapy is daily or near-daily doses of opioid medication. Compliance monitoring has been shown to be crucial in delivering proper opioid therapy and preserving this therapy for the future.
Urine drug testing (UDT) is a widely available and familiar method for monitoring opioid use in chronic pain patients. UDT can provide tools for tracking patient compliance and expose possible drug misuse and abuse. UDT is one of the major tools of adherence monitoring in the assessment of the patient’s predisposition to, and patterns of, misuse/abuse – a vital first step towards establishing and maintaining the safe and effective use of opioid analgesics in the treatment of chronic pain.
Frequency of Testing
A practical approach to UDT would include baseline drug testing, if appropriate; initiation of opioid therapy, and compliance monitoring within one to 3 months after baseline monitoring; and routine, random monitoring approximately every 6-12 months. Thus, the majority of patients will receive a baseline test, initiation of the compliance test, and one year monitoring within the first 15 months or so. After that, if the patient is continuing with a pain management program, testing will only be required once a year.
Types of Urine Drug Tests
Two types of urine drug screens are typically used, immunoassay and gas chromatography–mass spectrometry. Several factors need to be considered to determine the length of time a drug or substance can be detected in the urine, including:
POLICYOne (1) baseline urine drug test is considered medically necessary to determine if a patient has been exposed to opioids and other controlled substances prior to initiating chronic opioid therapy.
Urine drug testing for monitoring opioid use in patients with chronic non-cancer pain may be considered medically necessary up to two (2) times per year, unless there are inconsistencies (abnormalities) in the urine drug test results.
A confirmatory urine drug test is considered medically necessary only when there were inconsistencies (abnormalities) in the urine drug test results.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
POLICY HISTORY07/21/2012: Approved by Medical Policy Advisory Committee.
10/14/2013: Policy reviewed; no changes.
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 80300, 80301, 80302, 80303, 80304, and 80374. Added the following new 2015 HCPCS code to the Code Reference section: G6058.
08/31/2015: Medical policy revised to add ICD-10 codes.
12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to remove deleted CPT codes 80100, 80101, 80102, and 80104.
06/07/2016: Policy number L.2.04.422 added.
SOURCE(S)Pain Management Advisory Committee
Urine Drug Testing In Chronic Pain: Comprehensive Review, Paul J. Christo, MD1, Laxmaiah Manchikanti, MD2, Xiulu Ruan, MD3, Michael Bottros, MD1, Hans Hansen, MD4, Daneshvari R. Solanki, MD5, Arthur E. Jordan, MD6, and James Colson, MD7 Pain Physician 2011; 14:123-143 • ISSN 1533-3159 http://www.painphysicianjournal.com/2011/march/2011;14;123-143.pdf
Urine Drug Screening: A Practical Guide for Clinicians Karen E. Moeller, Kelly C. Lee, Julie C. Kissack, Mayo Clinic Proceedings, 2008 83(1): pp 66–76
Chronic Opioid Therapy (COT) Safety Guideline For Patients With Chronic Non-Cancer Pain, Copyright 2010–2012 Group Health Cooperative
This may not not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.