This Policy version was replaced on October 28, 2024. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-management, select 'See Medical and Behavioral Health Policies', then 'Blue Cross and Blue Shield of Minnesota Medical and Behavioral Health Policies'. This will bring up the Medical Policy search screen. Enter the policy number without the version number (last three digits). 

Drug testing methods are used for monitoring patients in substance use disorder treatment and those undergoing pain management treatment who may use non-prescribed drugs or misuse prescribed drugs, such as opioids. Samples on which testing may be done include urine, oral fluid, and hair. 

Urine is the most commonly used sample for drug testing in outpatient substance use disorder treatment and outpatient chronic pain management settings. The two major categories of urine drug testing (UDT) are presumptive drug testing and definitive drug testing. Presumptive tests are immunoassay tests that provide a positive or negative result for the presence of one or more drugs or drug classes based on a prespecified threshold, but do not indicate specific levels. These tests can be performed either in a laboratory or at point-of-care and generally have rapid turnaround time. Definitive tests confirm the presence of the specific drug identified in a screening test and quantify the amount of drug present. These tests are performed in a laboratory rather than at point-of-care which may result in slower turnaround time. Definitive tests can also be used to identify drugs that cannot be measured by immunoassays, such as certain synthetic or semisynthetic opioids.  Patients are often assessed by UDT before starting treatment and monitored while they are receiving treatment.

Oral fluid, samples obtained from the oral cavity, can potentially be used to test for drug use. However, the mixture of fluids (e.g. saliva, mucus) varies depending on the collection method used. In addition, drug concentrations can be affected by the collection method.

Hair composed of protein that traps chemicals in the blood at the time the hair develops in the follicle. Thus, hair can be used to detect drug use. Although it is easy to sample and it is difficult to substitute or adulterate, there are disadvantages for use in drug testing including inability to detect recent or light drug use, and test inaccuracy due to environmental exposure, variation in hair texture and cosmetic hair treatments.

Laboratory tests must meet the general regulatory standards of the Clinical Laboratory Improvement Amendments (CLIA). Certain point-of-care immunoassays are commercially available as CLIA-waived tests for drugs such as cocaine, methadone, morphine, and oxycodone.

Note:  This policy addresses use of drug testing in outpatient substance use disorder treatment or outpatient chronic pain management settings only. Use of blood as a sample for drug testing is outside the scope of this policy.

Definitions

Stabilization phase:  The stabilization and/or detoxification phase of treatment is for patients who experience withdrawal symptoms following prolonged drug abuse. This phase focuses on finding a medication dosage that will minimize withdrawal symptoms and cravings and decrease or eliminate drug abuse. Most patients in opioid treatment are expected to be on a stable dose of medication within 4 weeks of initiating treatment.

Maintenance phase:  The maintenance and/or rehabilitation phase of treatment follows the stabilization phase of treatment. This phase begins when a patient is responding optimally to medication treatment and routine dosage adjustments are no longer needed. For most patients in opioid treatment, targeted presumptive screening once every 1 to 3 months is sufficient during the maintenance phase of treatment.

Morphine equivalent dose (MED): A numeric value that describes the sum of the morphine milligram equivalents (MME's) of various opioid drugs prescribed for an individual over a period of time, usually per day.

I.  Presumptive Urine Drug Testing

• Presumptive urine drug testing for substance use disorder treatment may be considered MEDICALLY NECESSARY AND APPROPRIATE under any of the following conditions:
  • On initial entrance into substance use disorder treatment when all of the following criteria are met:
    • An adequate clinical assessment of patient history and risk of substance use is performed, including obtaining information from the state prescription drug monitoring program; AND
    • Clinicians have knowledge of test interpretation; AND
    • Clinical documentation specifies how the test result will be used to guide clinical decision making.
  • During the stabilization phase of treatment no more frequently than once a week for a maximum of 4 weeks.
  • During the maintenance phase of treatment: 
    • First 4 weeks of maintenance: No more frequently than every 2 weeks; 
    • After 4 weeks of maintenance: No more frequently than once a month unless patient is demonstrating aberrant behavior defined by one or more of the following:
      • Lost prescriptions;
      • Requests for early refills;
      • Obtained controlled substances from multiple providers;
      • Unauthorized dose escalation;
      • Apparent intoxication.
• Presumptive urine drug testing for chronic pain management may be considered MEDICALLY NECESSARY AND APPROPRIATE under any of the following conditions:
  • On initial entrance into chronic pain management when all of the following criteria are met:
    • An adequate clinical assessment of patient history and risk of substance use is performed, including obtaining information from the state prescription drug monitoring program; AND
    • Clinicians have knowledge of test interpretation; AND
    • Clinical documentation specifies how the test result will be used to guide clinical decision making.
  • During subsequent monitoring of treatment no more frequently than the following times according to the risk level of the individual, as determined by a validated screening tool for assessing the risk of aberrant drug-related behaviors (e.g., the Opioid Risk Tool [ORT] or the Screener and Opioid Assessment for Patients with Pain-Revised [SOAPP-R]);
    • Twice a year for patients who are low or moderate risk;
    • Four times a year for patients who are high risk OR receiving an opioid dose >120 mg MED/d;
    • For patients demonstrating aberrant behavior defined by one or more of the following:
      • Lost prescriptions;
      • Requests for early refills;
      • Obtained controlled substances from multiple providers;
      • Unauthorized dose escalation;
      • Apparent intoxication.
• Presumptive urine drug testing is considered NOT MEDICALLY NECESSARY in all other situations, including but not limited to routine testing (e.g. "standing orders") and testing for non-medical purposes.

II.  Definitive Urine Drug Testing

• Definitive urine drug testing for substance use disorder treatment or chronic pain management may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL of the following criteria are met:
  • Presumptive urine drug testing was performed according to the medically necessary criteria described in section I; AND
  • The result of presumptive urine drug testing was one or more of the following:
    • Positive for a non-prescribed drug with abuse potential; OR
    • Positive for an illicit drug (e.g., methamphetamine or cocaine); OR
    • Negative for prescribed medications; AND
  • Clinical documentation specifies supporting rationale for each definitive test ordered; AND
  • Clinical documentation specifies how the test result will be used to guide clinical decision making.
• Definitive urine drug testing for substance use disorder treatment or chronic pain management may be considered MEDICALLY NECESSARY AND APPROPRIATE when BOTH of the following criteria are met:
  • A presumptive test for the relevant drug(s) is not commercially available; AND
  • The testing is performed according to the medically necessary criteria described in section I, with the exception that it is definitive rather than presumptive testing.
• Definitive urine drug testing is considered NOT MEDICALLY NECESSARY in all other situations, including but not limited to routine testing (e.g. "standing orders") and testing for non-medical purposes.

III.  Drug testing using oral fluid or hair samples in outpatient substance use disorder treatment or outpatient chronic pain management settings is considered EXPERIMENTAL/INVESTIGATIVE due to the lack of clinical evidence demonstrating an impact on improved health outcomes.