COVERAGE
DETERMINATION
GUIDELINE
OPTUM™
By United Behavioral Health
Drug Testing
Guideline Number: BHCDG892015
Product:
Effective Date: June 2016
2001 Generic UnitedHealthcare COC/SPD
Revision Date:
2007 Generic UnitedHealthcare COC/SPD
2009 Generic UnitedHealthcare COC/SPD
2011 Generic UnitedHealthcare COC/SPD
Table of Contents:
Instructions for Use……………………….1
Related Coverage Determination
Guidelines:
Key Points…………………………………2
Office-Based Opioid Treatment
Benefits………………………….………....3
Opioid Treatment Program (Methadone
Maintenance)
Clinical Best Practices………….…..……5
Level of Care Criteria………….………….8
Treatment of Substance-Related and Addictive
Disorders
Additional Resources……………………10
Related Medical Policies:
Definitions………………………………...11
Level of Care Guidelines
References…………………………….....12
American Academy of Child and Adolescent
Psychiatry. Practice Parameter for the
Assessment and Treatment of Children and
Adolescents with Substance Use Disorders,
2005
Coding………………………………….....14
History……………………………………..15
American Psychiatric Association, Practice
Guideline for the Treatment of Patients with
Substance Use Disorders, 2006
American Psychiatric Association, Practice
Guideline Watch for the Treatment of Patients
with Substance Use Disorders, 2007
American Society of Addiction Medicine
Treatment Criteria for Addictive, SubstanceRelated and Co-Occurring Conditions, Third
Edition, 2013
INSTRUCTIONS FOR USE
This Coverage Determination Guideline provides assistance in interpreting behavioral health
benefit plans that are managed by Optum. This Coverage Determination Guideline is also
applicable to behavioral health benefit plans managed by Pacificare Behavioral Health and U.S.
Behavioral Health Plan, California (doing business as Optum California (“Optum-CA”).
Page 1 of 15
Coverage Determination Guideline
Confidential and Proprietary, © Optum 2016
Optum is a brand used by United Behavioral Health and its affiliates.
When deciding coverage, the enrollee specific document must be referenced. The terms of an
enrollee’s document (e.g., Certificates of Coverage (COCs), Schedules of Benefits (SOBs), or
Summary Plan Descriptions (SPDs) may differ greatly from the standard benefit plans upon which
this guideline is based. In the event that the requested service or procedure is limited or excluded
from the benefit, is defined differently, or there is otherwise a conflict between this document and
the COC/SPD, the enrollee's specific benefit document supersedes these guidelines.
All reviewers must first identify enrollee eligibility, any federal or state regulatory requirements
that supersede the COC/SPD and the plan benefit coverage prior to use of this guideline. Other
coverage determination guidelines and clinical guideline may apply.
Optum reserves the right, in its sole discretion, to modify its coverage determination guidelines
and clinical guidelines as necessary.
While this Coverage Determination Guideline does reflect Optum’s understanding of current best
practices in care, it does not constitute medical advice.
Key Points


This Coverage Determination Guideline is applicable to drug testing as an adjunct to the
assessment and treatment of Substance-Related Disorders. It is not applicable to other
circumstances such as the following:
o
The assessment or treatment other conditions (e.g., toxicology testing to establish if
conditions such as coma or stupor are the result of an overdose;
o
To establish the qualitative or quantitative presence of a controlled substance
prescribed for the treatment of conditions other than Substance-Related Disorders
(e.g., therapeutic drug monitoring of lithium for members with Bipolar Disorder);
o
Federally-regulated drug testing for Federal employees, and non-Federal employees
in safety-sensitive positions (e.g., pilots);
o
Drug testing related to sports;
o
At-home drug testing;
o
As a condition of participation in supportive living program (e.g., a sober living
arrangement).
Benefits are available for covered services that are not otherwise limited or excluded.
Examples of limitations and exclusions include testing related to:
o
Judicial or administrative proceedings or orders except when otherwise necessary;
o
Obtaining or maintaining a license;
o
Employment.

Benefits are not available for coverage of specimen validity testing.

Drug testing involving the analysis of urine is the most common and preferred method of
determining the presence or absence, or concentration of drugs of abuse; or determining
compliance with treatment.

Services should be consistent with evidence-based interventions and clinical best practices
as described in Part II, and should be of sufficient intensity to address the member's needs
(COC, 2007, 2009 & 2011).
Drug Testing
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PART I: BENEFITS
Before using this guideline, please check enrollee’s specific plan document and
applicable federal or state mandates.
Benefits
Benefits include the following services:

Diagnostic evaluation and assessment

Treatment planning

Referral services

Medication management

Individual, family, therapeutic group and provider-based case
management services

Crisis intervention
Covered Services
Covered Health Service(s) – 2001
Those health services provided for the purpose of preventing, diagnosing or
treating a sickness, injury, mental illness, substance abuse, or their symptoms.
A Covered Health Service is a health care service or supply described in Section
1: What's Covered--Benefits as a Covered Health Service, which is not excluded
under Section 2: What's Not Covered--Exclusions.
Covered Health Service(s) – 2007, 2009 and 2011
Those health services, including services, supplies, or Pharmaceutical Products,
which we determine to be all of the following:

Provided for the purpose of preventing, diagnosing or treating a sickness,
injury, mental illness, substance abuse, or their symptoms.

Consistent with nationally recognized scientific evidence as available, and
prevailing medical standards and clinical guidelines as described below.

Not provided for the convenience of the Covered Person, Physician,
facility or any other person.

Described in the Certificate of Coverage under Section 1: Covered Health
Services and in the Schedule of Benefits.

Not otherwise excluded in the Certificate of Coverage under Section 2:
Exclusions and Limitations.
In applying the above definition, "scientific evidence" and "prevailing medical
standards" shall have the following meanings:
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
"Scientific evidence" means the results of controlled clinical trials or other
studies published in peer-reviewed, medical literature generally
recognized by the relevant medical specialty community.

"Prevailing medical standards and clinical guidelines" means nationally
recognized professional standards of care including, but not limited to,
national consensus statements, nationally recognized clinical guidelines,
and national specialty society guidelines.
Pre-Service Notification
Admissions to an inpatient detoxification, residential detoxification, inpatient
rehabilitation, residential rehabilitation, partial hospital/day treatment program or
intensive outpatient programs require pre-service notification. Notification of a
scheduled admission must occur at least five (5) business days before
admission. Notification of an unscheduled admission (including Emergency
admissions) should occur as soon as is reasonably possible. Benefits may be
reduced if Optum is not notified of an admission to these levels of care. Check
the member’s specific benefit plan document for the applicable penalty and
provision for a grace period before applying a penalty for failure to notify Optum
as required.
Limitations and Exclusions
The requested service or procedure for the treatment of a Substance-Related
Disorder must be reviewed against the language in the enrollee's benefit
document. When the requested service or procedure is limited or excluded from
the enrollee’s benefit document, or is otherwise defined differently, it is the terms
of the enrollee's benefit document that prevails.
Inconsistent or Inappropriate Services or Supplies – 2001, 2007, 2009 &
2011
Services or supplies for the diagnosis or treatment of Mental Illness that, in the
reasonable judgment of the Mental Health/Substance-Related Disorder
Designee, are any of the following:

Not consistent with generally accepted standards of medical practice for
the treatment of such conditions.

Not consistent with services backed by credible research soundly
demonstrating that the services or supplies will have a measurable and
beneficial health outcome, and are therefore considered experimental.

Not consistent with the Mental Health/Substance-Related Disorder
Designee’s level of care guidelines or best practice guidelines as
modified from time to time.

Not clinically appropriate for the member’s Substance-Related Disorder
or condition based on generally accepted standards of medical practice
and benchmarks.
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All Other Exclusions – 2001, 2007, 2009, and 2011
Physical, psychiatric or psychological exams, testing, vaccinations,
immunizations or treatments that are otherwise covered under the Policy when:

Required solely for purposes of school, sports or camp, travel, career or
employment, insurance, marriage or adoption.

Related to judicial or administrative proceedings or orders.

Conducted for purposes of medical research.

Required to obtain or maintain a license of any type.
Additional Information
The lack of a specific exclusion that excludes coverage for a service does not
imply that the service is covered. The following are examples of services that are
inconsistent with the Level of Care Guidelines and Best Practice Guidelines (not
an all-inclusive list):

Services that deviate from the indications for coverage summarized
earlier in this document.

Drug tests or collection devices that are not approved by the FDA.

Drug testing that is routinely administered to all people seeking care
regardless of whether there is an indication of Substance-Related
Disorder (i.e., testing used for routine screening or surveillance.

Drug testing using multiple source specimens such as blood and urine
simultaneously.

Definitive Quantitative Test or other confirmation testing when there
hasn’t been a Presumptive Qualitative or other positive initial screen,
and the positive test results are inconsistent with the patient’s history.

Confirmation testing when there hasn’t been an initial screen, or
confirmation testing conducted for drug classes other than the one in
question.
Please refer to the enrollee’s benefit document for ASO plans with benefit
language other than the generic benefit document language.
PART II: CLINICAL BEST PRACTICE
1. Evaluation & Treatment Planning
1.1. Drug testing must be within the scope of the ordering provider’s
professional training and licensure. Further, the provider should be familiar
with clinical best practices for selecting and administering drug tests, as well
as interpreting and using results to inform treatment.
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1.2. Drug testing may be an adjunct to evaluation and treatment planning
when the history of alcohol and drug use is unreliable. In this
circumstance a qualitative drug test may be used to confirm:
1.2.1.
The member’s Substance-Related Disorder;
1.2.2.
Whether the member is currently using alcohol or drugs; or
1.2.3.
Whether the member is using substances in addition to those
reported.
1.3. The provider obtains informed consent from the member to conduct drug
testing. As part of obtaining informed consent, the provider informs the
member of the purpose of testing, how the results will be used, and any
mandatory state reporting requirements.
1.3.1.
In the event that the member refuses permission to conduct
drug testing, the refusal becomes an area of discussion. The
provider considers whether treatment can proceed without
drug testing.
1.4. The provider uses the results of the member’s medical and psychosocial
assessments to narrow test selection to that which is relevant and
impacts the treatment plan.
1.4.1. Test selection should be individualized based on the member’s
prior use, suspected use, prescribed medications, substances of
common use in the community and locale in which the specimen is
collected, and circumstantial considerations such as the
introduction of a substance into a treatment setting.
1.5. Urine is the specimen of choice for substance use with the exception of
alcohol. Urine testing is used to identify substances early in disease
progression, assess etiology of unexplained symptoms, formulate and
implement a treatment plan, evaluate the effectiveness of treatment, and
monitor compliance.
1.5.1. In certain situations, blood testing or testing of oral fluids may be a
suitable alternative.
1.5.2. Testing of other matrices such as hair, nails or breath is less
commonly employed because of limited utility (e.g., testing of
breath is limited to alcohol), or costliness such as with testing hair
or nails.
1.6. The frequency and duration of drug testing should be individualized
based on factors including the member’s history, current status, previous
laboratory findings, and stage of treatment or recovery; as well as the
suspected drugs of abuse, and the risk of additive or synergistic
interactions between drugs of abuse and prescribed medications.
Typically, testing is done less frequently as treatment progresses and
the member’s condition stabilizes.
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2. Drug Testing
2.1. The Clinical Laboratory Improvement Amendments (CLIA) regulates
laboratory testing and requires clinical labs to be certified by their State
as well as the CMS before they can accept human samples for diagnostic
testing. Multiple types of CLIA certificates may be obtained based on the
complexity of testing a lab conducts.
2.2. There are 3 CLIA classifications of tests: CLIA waived tests, moderate
complexity and high complexity tests.
2.3. Presumptive/Qualitative Drug Testing – (hereafter called “presumptive”
UDT) is used when necessary to determine the presence or absence of
drugs or drug classes in a urine sample. Results are expressed as
negative or positive or as a numerical result.
2.3.1. Qualitative drug testing is appropriate once during treatment
in a particular level of care to assess a member’s substance
use. Thereafter, Qualitative drug testing is appropriate if
there is an indication of relapse, and the clinical rationale is
documented in the member’s record.
2.3.2. Qualitative drug testing is used to confirm compliance with
treatment, but the frequency should be necessary and the
rationale documented in the member’s record.
2.3.3. Qualitative drug testing is also appropriate to determine
compliance with Medication-Assisted Treatment of an
Opioid-Related Disorder.
2.3.4. Presumptive UDT is limited in the following ways:
2.3.4.1.
Presumptive UDT primarily screens for drug classes
rather than specific drugs, and therefore, the
practitioner may not be able to determine if a different
drug within the same class is causing a positive
result;
2.3.4.2.
Presumptive UDT produces erroneous results due to
cross-reactivity with other compounds or does not
detect all drugs within a drug class;
2.3.4.3.
Not all prescription medications or synthetic/analog
drugs are detectable; it is unclear as to whether other
drugs are present;
2.3.4.4.
Cut-off value may be too high to detect presence of
drug
2.3.5. CLIA-waived tests are simple tests, and include “strips”,
“cards”, “cups”, “cassette” or certain office instruments.
These tests are often referred to a Point of Care Testing
(POCT).
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2.3.6. POCT is typically employed when immediate results are
needed for the management of the member’s condition.
POCT is more limited and typically does not offer the degree
of specificity and sensitivity as laboratory testing. The
provider should consider the potential for false positive and
false negative results.
2.3.7. The provider refers to the information in the POCT kit’s insert
to determine the test’s capability to detect the substances
and must follow the manufacturer’s specific instructions for
test administration.
2.3.8. Positive test results are presumptive or not definitive due to
sensitivity and cross-reactivity limitations. Negative test
results do not necessarily indicate the absence of a drug or
substance in the urine specimen. The accuracy of the results
of a CLIA-waived presumptive UDT will depend on the
testing environment, type of test, and training of the
individual conducting the test.
2.3.9. Most positive screening results are confirmed by the
patient’s self-disclosed admission of substance use.
2.3.10. Ongoing monitoring without confirmation or quantitative
testing is typically sufficient for the following drugs/drug
classes:
2.3.10.1. Alcohol
2.3.10.2. Amphetamines/Methamphetamines/MDMA
2.3.10.3. Barbiturates
2.3.10.4. Benzodiazepines
2.3.10.5. Cannabinoids
2.3.10.6. Cocaine
2.3.10.7. Methadone
2.3.10.8. Opiates
2.3.10.9. Oxycodone
2.3.11. Moderate and high complexity immunoassay tests are
more complex than CLIA waived tests, and can be
performed by automated clinical laboratory equipment or
require additional clinical laboratory expertise.
2.3.12. Both moderate and high complexity tests must meet CLIA
quality requirements.
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Page 8 of 15
2.4. Definitive/Quantitative/Confirmation (hereafter called “definitive” UDT)
drug testing is used when it is necessary to identify specific medications,
illicit substances and metabolites. Definitive UDT reports the results of
drugs absent or present in concentrations of ng/ml. It is limited to Gas
Chromatography-mass spectrometry (GS-MS) and Liquid
Chromatography-mass spectrometry (MS/MS) testing methods.
2.5. Definitive UDT is reasonable and necessary based on patient specific
indications including historical use, medication response, and clinical
assessment, when accurate results are necessary to make clinical
decisions. The clinician’s rationale for the definitive UDT and the tests
ordered must be documented in the member’s record.
2.6. Definitive UDT is reasonable and necessary in the following
circumstances:
2.6.1. To identify a specific substance or metabolite that is
inadequately detected by a presumptive UDT screen;
2.6.2. To definitively identify specific drugs in a large family of
drugs;
2.6.3. To identify a specific substance or metabolite that is not
detected by presumptive UDT such as fentanyl, Meperidine,
synthetic cannabinoids and other synthetic/analog drugs;
2.6.4. To identify drugs when a definitive concentration of a drug is
needed to guide management (e.g., discontinuation of THC
use according to a treatment plan);
2.6.5. To identify a negative, or confirm a positive, presumptive
UDT result that is inconsistent with a patient’s self-report,
presentation, medical history, or current prescribed pain
medication plan;
2.6.6. To rule out an error as the cause of an unexpected
presumptive UDT result;
2.6.7. To identify non-prescribed medication or illicit use for
ongoing safe prescribing of controlled substances; and
2.6.8. To use in a differential assessment of medication efficacy,
side effects, or drug-drug interactions.
2.7. In the event that a member, who is or could be pregnant, is undergoing
Medication-Assisted Treatment, the provider verifies that the member is
taking the medication as directed, and not consuming illicit, nonprescribed substances within the same class as the prescribed
medication. A Definitive Quantitative Test should be performed to
identify varying substances within a single class when clinically
appropriate.
Drug Testing
Page 9 of 15
2.8. Definitive quantitative urine testing for alcohol metabolites may be
advisable, but to rapidly detect alcohol use at the time of patient
encounter, breath tests are typically considered appropriate. If the
provider believes the member has produced adulterated or substituted
urine, and no alternative matrix sampling is available (i.e., blood or
saliva), the provider should consider witnessed urine collection.
2.9. Physician-directed definitive profile testing is reasonable and necessary
when ordered for a member based upon historical use and community
trends. However, the same physician-defined profile is not reasonable
and necessary for every patient in a physician’s practice. Definitive UDT
orders should be individualized based on clinical history and risk
assessment, and must be documented in the member’s record.
2.9.1. A “profile” differs from a “panel” or “blanket order” in that a
profile responds to the clinical risks of a particular patient,
whereas a panel encourages unnecessary or excessive
testing when no clinical cause exists.
2.10. Confirmation testing is generally used to evaluate initial qualitative
screening results to minimize the potential of a clinician relying on a
false negative or positive result.
2.10.1. Confirmation testing is often recommended when initial
screening involves a CLIA-waived or moderate complexity
immunoassay screening, but is not necessary in all patient
cases.
2.10.2. A confirmation test order must be necessary and
reasonable and patient self-report may, in some cases,
reduce the need for confirmation of screening results. The
use of qualitative versus quantitative confirmation testing
depends upon the individual patient’s case and necessity
therefore.
PART IV: ADDITIONAL RESOURCES
Clinical Protocols
Optum maintains clinical protocols that include the Level of Care Guidelines and
Best Practice Guidelines which describe the scientific evidence, prevailing
medical standards and clinical guidelines supporting our determinations
regarding treatment. These clinical protocols are available to Covered Persons
upon request, and to Physicians and other behavioral health care professionals
on Provider Express.
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Peer Review
Optum will offer a peer review to the provider when services do not appear to
conform to this guideline. The purpose of a peer review is to allow the provider
the opportunity to share additional or new information about the case to assist
the Peer Reviewer in making a determination including, when necessary, to
clarify a diagnosis.
Second Opinion Evaluations
Optum facilitates obtaining a second opinion evaluation when requested by an
enrollee, provider, or when Optum otherwise determines that a second opinion is
necessary to make a determination, clarify a diagnosis or improve treatment
planning and care for the member.
Referral Assistance
Optum provides assistance with accessing care when the provider and/or
enrollee determine that there is not an appropriate match with the enrollee’s
clinical needs and goals, or if additional providers should be involved in delivering
treatment.
PART V: DEFINITIONS
Confirmation Testing Re-testing used to evaluate initial qualitative screening
results to minimize the potential of a clinician relying on a false negative or
positive result.
Drug Testing The analysis of urine, saliva or serum to confirm the presence or
absence, or concentration of drugs of abuse.
Drug of Abuse A substance used by a person who has a Substance-Related
Disorder. Drugs of abuse include illicit substances, medications when not used
as prescribed, and alcohol.
Medication-Assisted Treatment The use of medications, in combination with
counseling and behavioral therapies, to provide a whole-patient approach to the
treatment of substance use disorders.
Motivational Interviewing A patient-centered counseling approach for initiating
behavior change by helping patients to resolve ambivalence about engaging in
treatment and stopping substance use. This approach employs strategies to
evoke rapid and internally motivated change in the patient, rather than guiding
the patient stepwise through the recovery process.
Opioid Treatment Services Opioid Treatment Programs (Methadone
Maintenance) or Office-Based Opioid Treatment used to treat Opioid Use
Disorder.
Point of Care Testing (POCT) Testing conducted at the site of care. POCT is
typically employed when immediate results are needed for the immediate
management of the member’s condition, as opposed to testing carried out in an
offsite laboratory.
Drug Testing
Page 11 of 15
Prevailing Medical Standards and Clinical Guidelines means nationally
recognized professional standards of care including, but not limited to, national
consensus statements, nationally recognized clinical guidelines, and national
specialty society guidelines.
Qualitative Drug Testing A form of drug testing used to determine the presence
or absence of drugs of abuse.
Quantitative Drug Testing A form of drug testing used to determine the
concentration of drugs present in the body.
Scientific Evidence The results of controlled clinical trials or other studies
published in peer-reviewed, medical literature generally recognized by the
relevant medical specialty community.
Specimen Validity Testing Testing to ensure that a urine specimen is
consistent with normal human urine and has not been corrupted or replaced.
Substance-Related Disorders A cluster of cognitive, behavioral, and
physiological symptoms indicated that the individual continues using the
substance despite significant substance related problems. The diagnosis is
based on a pathological pattern of behaviors related to the use of any of the 10
classes of drugs identified in the DSM.
Therapeutic Drug Monitoring An application of testing used to establish the
qualitative or quantitative presence of a controlled substance prescribed for the
treatment of a medical or behavioral health condition.
Toxicology Testing An application of testing used to determine if medical
conditions such as stupor or coma are the result of an overdose.
Urine Drug Test A type of laboratory test used to confirm the presence or
absence of drugs of abuse in the member’s urine.
PART VI: REFERENCES
1. American Academy of Child and Adolescent Psychiatry. (2007). Practice
Parameter for the Assessment and Treatment of Children and Adolescents
with Substance Use Disorders. Retrieved from
http://download.journals.elsevierhealth.com/pdfs/journals/08908567/PIIS0890856709616415.pdf.
2. American Psychiatric Association. (2006). Practice Guideline for the
Treatment of Patients with Substance Use Disorders. Retrieved from
http://psychiatryonline.org/guidelines.aspx.
3. American Psychiatric Association. (2007). Practice Guideline for the
Treatment of Patients with Substance Use Disorders, Guideline Watch.
Retrieved from http://psychiatryonline.org/guidelines.aspx.
4. American Society of Addiction Medicine. (2013). Drug Testing: A White Paper
of the American Society of Addiction Medicine. Retrieved from
http://www.asam.org/docs/default-source/publicy-policy-statements/drugtesting-a-white-paper-by-asam.pdf?sfvrsn=0.
Drug Testing
Page 12 of 15
5. American Society of Addiction Medicine. (2010). Public Policy Statement on
Drug Testing As a Component of Addiction Treatment and Monitoring
Programs in Clinical Settings. Retrieved from
http://www.asam.org/docs/publicy-policy-statements/1drug-testing---clinical10-10.pdf.
6. Centers for Medicare & Medicaid Services. (2015). Clinical Laboratory
Improvement Amendments (CLIA). Retrieved from
https://www.cms.gov/Regulations-andGuidance/Legislation/CLIA/index.html?redirect=/clia/.
7. Centers for Medicare and Medicaid Services. (2015). Local Coverage
Determination, Controlled Substance Monitoring and Drugs of Abuse Testing
(L35105). Retrieved from: http://www.cms.gov/medicare-coveragedatabase/indexes/national-and-local-indexes.aspx.
8. Centers for Medicare and Medicaid Services. (2014). Local Coverage
Determination, Drugs of Abuse Testing (L34457). Retrieved from:
http://www.cms.gov/medicare-coverage-database/indexes/national-and-localindexes.aspx.
9. Centers for Medicare and Medicaid Services. (2015). Local Coverage
Determination, Drug Testing (L32450). Retrieved from:
http://www.cms.gov/medicare-coverage-database/indexes/national-and-localindexes.aspx.
10. Centers for Medicare and Medicaid Services. (2015). Local Coverage
Determination, Qualitative Drug Screening (L28154). Retrieved from:
http://www.cms.gov/medicare-coverage-database/indexes/national-and-localindexes.aspx.
11. Centers for Medicare and Medicaid Services. (2015). Local Coverage
Determination, Qualitative Drug Screening (L30574). Retrieved from:
http://www.cms.gov/medicare-coverage-database/indexes/national-and-localindexes.aspx .
12. Centers for Medicare and Medicaid Services. (2015). Local Coverage
Determination, Qualitative Drug Testing (L34352). Retrieved from:
http://www.cms.gov/medicare-coverage-database/indexes/national-and-localindexes.aspx.
13. Centers for Medicare and Medicaid Services. (2006). Clinical Laboratory
Improvement Amendments (CLIA): How to Obtain a CLIA Certificate of
Waiver. Retrieved from http://www.cms.gov/Regulations-andGuidance/Legislation/CLIA/downloads/howobtaincertificateofwaiver.pdf.
14. Code of Federal Regulations. (2015). 42 CFR 8.12, Federal Opioid Treatment
Standards. Retrieved from: http://www.ecfr.gov/cgi-bin/textidx?SID=b6101f96d5b3af2e841a91bd7f1ce478&mc=true&node=se42.1.8_11
2&rgn=div8.
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Page 13 of 15
15. Diagnostic and Statistical Manual of Mental Disorders, 5th ed.; DSM-5;
American Psychiatric Association, 2013.
16. Melanson, SE. (2012). The Utility of Immunoassays for Urine Drug Testing.
Clinics in Laboratory Medicine, 32(3): 429-447.
17. Generic UnitedHealthcare Certificate of Coverage, 2001.
18. Generic UnitedHealthcare Certificate of Coverage, 2007.
19. Generic UnitedHealthcare Certificate of Coverage, 2009.
20. Generic UnitedHealthcare Certificate of Coverage, 2011.
21. Mee-Lee, D, Shulman GD, Fishman MJ, Gasfriend, DR, Mill MM, eds. The
ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and CoOccurring Conditions. 3rd ed. Carson City, NV: The Change Companies;
2013.
22. Optum Level of Care Guidelines (2015).
23. Substance Abuse and Mental Health Services Administration. (2012). Clinical
Drug Testing in Primary Care. Technical Assistance Publication (TAP) 32.
Retrieved from http://store.samhsa.gov/product/TAP-32-Clinical-DrugTesting-in-Primary-Care/SMA12-4668.
24. Substance Abuse and Mental Health Service Administration. (2009). Treatment
Improvement Protocol 43, Medication Assisted Treatment for Opioid Addiction in
Opioid Treatment Programs. Retrieved from:
http://store.samhsa.gov/list/series?name=TIP-Series-Treatment-ImprovementProtocols-TIPS-.
PART VII: CODING
The Current Procedural Terminology (CPT) codes and HCPCS codes listed in this guideline are
for reference purposes only. Listing of a service code in this guideline does not imply that the
service described by this code is a covered or non-covered health service. Coverage is
determined by the benefit document.
Limited to specific CPT and HCPCS codes?
Drug Testing
 Yes X No
Page 14 of 15
Limited to specific diagnosis codes?
305.00; 303.90; 303.90
303.00
291.81
305.2; 304.3; 304.3
292.89
292.0
305.90; 304.60; 304.60
305.30; 304.50; 304.50
292.89
292.89
292.89
305.90; 304.60; 304.60
292.89
305.50; 304.00; 304.00
292.89
292.0
305.40; 304.10; 304.10
292.89
292.0
305.70; 305.60; 305.70 (mild); 304.40; 304.20;
304.40 (moderate); 304.40; 304.20; 304.40
(severe)
292.89
292.0
X Yes  No
Alcohol Use Disorder (mild, moderate, severe)
Alcohol Intoxication
Alcohol Withdrawal
Cannabis Use Disorder (mild, moderate,
severe)
Cannabis Intoxication
Cannabis Withdrawal
Phencyclidine Use Disorder (mild, moderate,
severe)
Other Hallucinogen Use Disorder (mild,
moderate, severe)
Phencyclidine Intoxication
Other Hallucinogen Intoxication
Hallucinogen Persisting Perception Disorder
Inhalant Use Disorder (mild, moderate, severe)
Inhalant Intoxication
Opioid Use Disorder (mild, moderate, severe)
Opioid Intoxication
Opioid Withdrawal
Sedative, Hypnotic, or Anxiolytic Use Disorder
(mild, moderate, severe)
Sedative, Hypnotic, or Anxiolytic Intoxication
Sedative, Hypnotic, or Anxiolytic Withdrawal
Stimulant Use Disorder (amphetamine;
cocaine; other stimulant)
Stimulant Intoxication
Stimulant Withdrawal
Limited to place of service (POS)?
 Yes X No
Limited to specific provider type?
X Yes  No
Prescribing Practitioner (e.g., Psychiatrist,
Addictionologist)
Limited to specific revenue codes?
 Yes X No
PART VIII: HISTORY
Revision Date
6/2015
6/2016
Drug Testing
Name
G. Niewenhous
G. Niewenhous
Revision Notes
Version 1-Final
Version 2-Final
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