evekhm/cms_iom_500 huggingface dataset:
Proposed LCD - Urine Drug Testing (DL36668)
CLIA-Certified Laboratories-Informational onlyCLIA specifies quality standards for proficiency testing, facility administration, general laboratory systems, pre-analytic, analytic and post-analytic systems, onsite supervision requirements, personnel qualifications and responsibilities, quality control, and quality assessment.3High complexity laboratories must ensure that testing is carried out by onsite qualified, trained personnel using validated reliable methods compliant with regulatory procedures (42 CFR Part 493). Both GC-MS and LC-MS/MS require a quality program to monitor the quality and audit the competency of the staff. LC-MS/MS instrument maintenance must be performed daily as well as the validation of instrument performance prior to patient specimens. Final review and approval of GC-MS and LC-MS/MS results must be performed by a qualified clinical laboratory scientist as defined in 42 CFR Part 493.1489 (Testing Personnel Qualifications). A GC-MS or LC-MS/MS laboratory must have a qualified laboratory director, qualified physician, or qualified clinical laboratory scientist, as provided in 42 CFR 493.1443 (Laboratory Director Qualifications).Purpose of UDT:Presumptive UDT may be ordered by the clinician caring for a beneficiary when it is necessary to rapidly obtain and/or integrate results into clinical assessment and treatment decisions.Definitive UDT is considered reasonable and necessarywhen the clinical information supplied supports the definitive testing as in:Identify a specific substance or metabolite that is inadequately detected by a presumptive UDT screen;Definitively identify specific drugs in a large family of drugs;Identify a specific substance or metabolite that is not detected by presumptive UDT such as fentanyl, meperidine, synthetic cannabinoids and other synthetic/analog drugs;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);Identify a negative, or confirm a positive, presumptive UDT result that is inconsistent with a patients self-report, presentation, medical history, or current prescribed pain medication plan;Rule out an error as the cause of a presumptive UDT result;Identify non-prescribed medication or illicit use for ongoing safe prescribing of controlled substances; andUse in a differential assessment of medication efficacy, side effects, or drug-drug interactions.
Proposed LCD - Urine Drug Testing (DL36668)
Definitive UDT may be 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.1To establish that a test is reasonable and necessary,the clinicians rationale for the definitive UDT and the tests ordered must be documented in the patients medical record.Drug Testing PanelsPresumptive UDT PanelsPresumptive UDT typically involves testing for multiple analytes based on the specific beneficiary's clinical history and risk assessment and must be documented in the medical record. May be ordered as a panel and billed a "Per Patient encounter" regardless of the number of analytes tested.Definitive UDT PanelsPhysician-directed definitive profile testing is reasonable and necessary when ordered for a particular patientbased upon historical use, clinical findings, and community trends.However, the same physician-defined profile is not reasonable and necessary for every patient in a physicians practice.Definitive UDT orders should be individualized based on clinical history and risk assessment, and must be documented in the medical record.
Proposed LCD - Urine Drug Testing (DL36668)
Specimen TypeUrine or oral fluid is the preferred biologic specimen for testing because of the ease of collection, storage, and cost-effectiveness.1UDT cannot detect the dosage of drug ingested/used, the time of use, or the means of delivery (intravenous vs. oral vs. inhaled). Detection time of a substance in urine is typically 1-3 days depending on the drug, rate of metabolism, and rate of excretion. Lipid-soluble drugs, such as marijuana, may remain in body fat and be detected upwards of a week or more.Ethanol is not discussed in this LCD:Note: Ethanol is a known drug of abuse but is routinely tested in blood, not urine. In addition, the DEA Resource Guide8states that alcohol is exempt from control by the Controlled Substances Act (CSA). Ethanol is not under discussion in this LCD.Covered Indications for UDTGroup A  Symptomatic patients, Multiple drug ingestion, and/or Patients with unreliable historyA patient who presents in a variety of medical settings with signs or symptoms of substance use toxicity will be treated presumptively to stabilize the patient while awaiting presumptive, then definitive testing to determine the cause(s) of the presentation. The need for definitive UDT is based upon presumptive test findings, responses to medical interventions, and treatment plan.1A presumptive UDT should be performed as part of the evaluation and management of a patient who presents in an emergency room or urgent care setting with any 1 of the following:Coma;Altered mental status in the absence of a clinically defined toxic syndrome or toxidrome;Severe or unexplained cardiovascular instability (cardiotoxicity);Unexplained metabolic or respiratory acidosis in the absence of a clinically defined toxic syndrome or toxidrome;Seizures with an undetermined history;To provide antagonist to specific drug.
Proposed LCD - Urine Drug Testing (DL36668)
The presumptive findings, definitive drug tests ordered, and reasons for the testing must be documented in the patient's medical record.Group B - Diagnosis and treatment for substance abuse or dependenceA patient in active treatment for a SUD or monitoring across different phases of recovery may undergo medical management for a variety of medical conditions. A physician who is writing prescriptions for medications to treat either the SUD or other conditions may need to know if the patient is taking substances which can interact with prescribed medications or taking prescribed medications as expected.1The risk of drug-drug interactions is inherent to the patient and may be compounded by prescribed medications. UDT is a medically necessary and useful component of chemical dependency diagnosis and treatment. The UDT result influences treatment and level of care decisions.3Ordered tests and testing methods (presumptive and/or definitive) must match the stage of screening, treatment, or recovery; the documented history; and Diagnostic and Statistical Manual of Mental Disorders (DSM V) diagnosis. For patients with no known indicators of risk for SUD, the clinician may screen for a broad range of commonly abused drugs using presumptive UDT. For patients with known indicators of risk for SUD, the clinician may screen for a broad range of commonly abused drugs using definitive UDT. For patients with a diagnosed SUD, the clinician should perform random UDT at random intervals in order to properly monitor the patient.3Testing profiles must be determined by the clinician based on the following medical necessity guidance criteria:Patient history, physical examination, and previous laboratory findings;Stage of treatment or recovery;Suspected abused substance;Substances that may present high risk for additive or synergistic interactions with prescribed medication (e.g., benzodiazepines, alcohol).The patients medical recordmust include an appropriate number of UDTs billed over time based on the stage of screening, treatment, or recovery10; the rationale for the drugs/drug classes ordered; and the results must be documented in the medical record and used to direct care.3Maximum Number of Allowed Presumptive UDTs for SUDThe number of UDTs billed over time must meet medical necessity and be documented in the patients medical record.9
Proposed LCD - Urine Drug Testing (DL36668)
Maximum Number of Allowed Presumptive UDTs for SUDThe number of UDTs billed over time must meet medical necessity and be documented in the patients medical record.9For patients with0 to 30 consecutive days of abstinence, presumptive UDT is not to exceed 3 presumptive UDTs in a rolling 7 days. More than 3 presumptive UDTs in a rolling 7 days is not reasonable and necessary and is not covered by Medicare.For patients with31 to 90 consecutive days of abstinence, presumptive UDT is not to exceed 3 presumptive UDTs in a rolling 7 days. More than 3 presumptive UDTs in a rolling 7 days is not reasonable and necessary and is not covered by Medicare.For patients with> 90 consecutive days of abstinence, presumptive UDT is not to exceed 3 presumptive UDTs in a rolling 30 days. More than 3 presumptive UDTs in a rolling 30 days is not reasonable and necessary and is not covered by Medicare.Maximum Number of Allowed Definitive UDTs for SUD:Depending on the patients specific substance use history, definitive UDT to accurately determine the specific drugs in the patients system may be necessary. Definitive testing may be ordered when accurate and reliable results are necessary to integrate treatment decisions and clinical assessment. The number of UDTs billed over time and the rationale for definitive UDT must be documented in the patients medical record.For patients with0 to 30 consecutive days of abstinence, definitive UDT is not to exceed 1 definitive UDT in a rolling 7 days. More than 1 definitive UDT in a rolling 7 days is not reasonable and necessary and is not covered by Medicare.For patients with31 to 90 consecutive days of abstinence, definitive UDT is not to exceed 3 definitive UDTs in a rolling 30 days. More than 3 definitive UDTs in a rolling 30 days is not reasonable and necessary and is not covered by Medicare.For patients with> 90 days of consecutive abstinence, definitive UDT is not to exceed 3 definitive UDTs in a rolling 90 days. More than 3 definitive UDTs in a rolling 90 days is not reasonable and necessary and is not covered by Medicare.Group C - Treatment for patients on chronic opioid therapy (COT).
Proposed LCD - Urine Drug Testing (DL36668)
Group C - Treatment for patients on chronic opioid therapy (COT).A physician who is writing prescriptions for medications to treat chronic pain can manage a patient better if the physician knows whether the patient is consuming another medication or substance, which could suggest the possibility of SUD or lead to drug-drug interactions. Additionally, UDT may help the physician monitor for medication adherence, diversion, efficacy, side effects, and patient safety in general.11A broad cross section of the general population will develop either cancer pain syndrome or non-cancer pain which will require prolonged or chronic opioid therapy for management with normal risk of addiction inherent to the substance(s) exposed.12COT UDT Testing Objectives:Identifies absence of prescribed medication and potential for abuse, misuse, and diversion;Identifies undisclosed substances, unsanctioned prescription medication, or illicit substances;Identifies substances that contribute to adverse events or drug-drug interactions;Provides objectivity to the treatment plan11;Reinforces therapeutic compliance with the patient;Provides additional documentation demonstrating compliance with patient evaluation and monitoring13;Provide diagnostic information to help assess individual patient response to medications (e.g., metabolism, side effects, drug-drug interaction, etc.) over time for ongoing management of prescribed medications.Medical Necessity Guidance:Criteria to establish medical necessity for UDT must be based on patient-specific elements identified during the clinical assessment, and documented by the clinician in the patients medical record and minimally include the following elements14:Patient history, physical examination, and previous laboratory findings;Current treatment plan;Prescribed medication(s);Risk assessment plan.
Proposed LCD - Urine Drug Testing (DL36668)
Patient history, physical examination, and previous laboratory findings;Current treatment plan;Prescribed medication(s);Risk assessment plan.National pain organizations, physician societies, and the Federation of State Medical Boards15recommend a practical management approach to definitive UDT for COT. The number of UDTs billed overt time beyond the baseline presumptive UDT must be based on individual patient needs substantiated by documentation in the patients medical record. Recommendations for the ordering of presumptive and definitive UDT for patients on COT are as follows:3.COT Baseline Testing:Depending on the patients specific circumstances, initial presumptive and/or definitive COT patient testing may include amphetamine/ methamphetamine, barbiturates, benzodiazepines, cocaine, methadone, oxycodone, tricyclic antidepressants, tetrahydrocannabinol, opioids, opiates, heroin, and synthetic/analog or designer drugs.4.COT Monitoring Testing:Ongoing testing may be medically reasonable and necessary based on the patient history, clinical assessment, including medication side effects or inefficacy, suspicious behaviors, self-escalation of dose, doctor-shopping, indications/symptoms of illegal drug use, evidence of diversion, or other clinician documented change in affect or behavioral pattern.16As part of the clinical evaluation of the patient, the provider should inquire about prescription compliance and potential issues of abuse or diversion such as lost prescriptions, early refill requests, or requests for escalating dose of medication.16The number of UDTs billed over time must be based on the individuals risk potential.1Appropriate number of UDTs billed over time based on risk is listed in the table below.14The clinician should perform random UDT at random intervals to properly monitor a patient.17UDT testing does not have to be associated with an office visit.Patients with specific symptoms of medication aberrant behavior or misuse may be tested in accordance with this documents guidance for monitoring patient adherence and compliance during active treatment (<90 days) for substance use or dependence.UDT Frequency Based on Risk Assessment and Stratification*:Testing must be based on clinicians documented medical necessity and reviewed by the clinician in the management of prescribing/renewing a controlled substance for every risk group outlined below.
Proposed LCD - Urine Drug Testing (DL36668)
Testing must be based on clinicians documented medical necessity and reviewed by the clinician in the management of prescribing/renewing a controlled substance for every risk group outlined below.Risk GroupBaselineFrequency of TestingLow RiskPrior toInitiation ofCOTPresumptive and definitive UDT not to exceed 2 times each in a rolling 365 days for prescribed medications, non-prescribed medications that may pose a safety risk if taken with prescribed medications, and illicit substances based on patient history, clinical presentation, and/or community usage.Moderate RiskPrior toInitiation ofCOTPresumptive and definitive UDT not to exceed 2 times each in a rolling 180 days for prescription medications, non-prescribed medication that may pose a safety risk if taken with prescribed medications, and illicit substances, based on patient history, clinical presentation, and/or community usage.High RiskPrior to Initiation of COTPresumptive and definitive UDT not to exceed 3 times each in a rolling 90 days for prescribed medications, non-prescribed medications that may pose a safety risk if mixed with prescribed and illicit substances based on patient history, clinical presentation and/or community usage.*Note: Any additional definitive UDT beyond recommendations above must be justified by the clinician in the medical situations in which changes in prescribed medications may be needed, such as:Patient response to prescribed medication suddenly changes;Patient side effect profile changes;To assess for possible drug-drug interactions;Change in patients medical condition or behavior;Patient admits to use of illicit or non-prescribed controlled substance.
Proposed LCD - Urine Drug Testing (DL36668)
Patient response to prescribed medication suddenly changes;Patient side effect profile changes;To assess for possible drug-drug interactions;Change in patients medical condition or behavior;Patient admits to use of illicit or non-prescribed controlled substance.Opioid Risk Tool:The patients risk category must be clearly defined in the medical record and is essential in determining number of UDTs billed over time and medical necessity.This TOOL is to be used as a suggestion for defining Risk and this document is just an example and other tools accepted by the Opioid Use treating community may be used. Example, accepted by SAMHSA (Substance Abuse and Mental Health Services Administration)The Opioid Risk Tool (ORT)18is a brief, self-report screening tool designed for use with adult patients in primary care settings to assess risk for opioid abuse among individuals prescribed opioids for treatment of chronic pain.15,16Patients categorized as high-risk are at increased likelihood of future abusive drug-related behavior.14The ORT can be administered and scored in less than 1 minute and has been validated in both male and female patients, but not in non-pain populations. This tool should be administered to patients upon an initial visit prior to beginning opioid therapy for pain management. A score of 3 or lower indicates low risk for future opioid abuse, a score of 4 to 7 indicates moderate risk for opioid abuse, and a score of 8 or higher indicates a high risk for opioid abuse.15, 18Mark each box that appliesFemaleMaleFamily history of substance abuseAlcoholIllegal drugsRx drugsPersonal history of substance abuseAlcoholIllegal drugsRx drugsAge between 16-45 yearsHistory of preadolescent sexual abusePsychological diseaseADD, OCD, bipolar, schizophreniaDepressionScoring totalsOther Covered ServicesReflex Testing by Reference Laboratories  since reference laboratories do not have access to patient-specific data, reflex testing under the following circumstances is reasonable and necessary:To verify a presumptive positive UDT using definitive methods that include but are not limited to GC-MS or LC-MS/MS before reporting the presumptive finding to the ordering clinician and without an additional order from the clinician; orTo confirm the absence of prescribed medications when a negative result is obtained by presumptive UDT in the laboratory for a prescribed medication listed by the ordering clinician.
Proposed LCD - Urine Drug Testing (DL36668)
When medical record documentation that is individualized for a particular patient satisfies medical necessity requirements found elsewhere in this LCD (e.g., risk assessment, frequency), direct to definitive UDT without a presumptive UDT may be reasonable and necessary.Definitive testing to confirm a negative presumptive UDT result, upon the order of the clinician, is reasonable and necessary in the following circumstances:The result is inconsistent with a patients self-report, presentation, medical history, or current prescribed medication plan (should be present in the sample);Following a review of clinical findings, the clinician suspects use of a substance that is inadequately detected or not detected by a presumptive UDT; orWhen there is an unexpected negative presumptive UDT result, and it is clinically imperative to know if it is truly positive or negative; the medical record should state such.Definitive testing to confirm a presumptive UDT positive result, upon the order of the clinician, is reasonable and necessary when the result is inconsistent with the expected result, a patients self-report, presentation, medical history, or current prescribed medication plan.Non-Covered Services
Proposed LCD - Urine Drug Testing (DL36668)
Non-Covered ServicesBlanket Orders-same orders for all patients in a health care provider's practice.Reflex definitive UDT is not reasonable and necessary when presumptive testing is performed at point of care because the clinician may have sufficient information to manage the patient. If the clinician is not satisfied, he/she must determine the clinical appropriateness of and order specific subsequent definitive testing (e.g., the patient admits to using a particular drug, or the IA cut-off is set at such a point that is sufficiently low that the physician is satisfied with the presumptive test result).Routine standing orders for all patients in a physicians practice are not reasonable and necessary.It is not reasonable and necessary for a physician to perform presumptive POCT and order presumptive IA testing from a reference laboratory. In other words, Medicare will only pay for one presumptive test result per patient per date of service regardless of the number of billing providers.It is not reasonable and necessary for a physician to perform presumptive IA testing and order presumptive IA testing from a reference laboratory. Medicare will only pay for one presumptive test result per patient per date of service regardless of the number of billing providers.It is not reasonable and necessary for a reference laboratory to perform and bill IA presumptive UDT prior to definitive testing without a specific physicians order for the presumptive testing.IA testing, regardless of whether it is qualitative or semi-quantitative (numerical), may not be used to confirm or definitively identify a presumptive test result obtained by cups, dipsticks, cards, cassettes or other IA testing methods. Definitive UDT provides specific identification and/or quantification typically by GC-MS or LC-MS/MS. Semi-Quantitative is defined as a numerical estimation of the approximate concentrations.Drug testing of 2 different specimen types from the same patient on the same date of service for the same drugs/metabolites/analytes.UDT for medico-legal and/or employment purposes or to protect a physician from drug diversion charges.Specimen validity testing including, but not limited to, pH, specific gravity, oxidants, creatinine.General InformationAssociated InformationN/ASources of InformationOther Contractor(s)' PoliciesBibliography
Proposed LCD - Urine Drug Testing (DL36668)
DuPont RL, Shea CL, Barthwell AG, et al. DRUG TESTING: A White Paper of the American Society of Addiction Medicine (ASAM). American Society of Addiction Medicine. White Paper. 2013.Gourlay DL, Heit HA, Caplan YH. Urine drug testing in clinical practice. The art and science of patient care. 2015(6):1-30SAMHSA, Clinical DRUG TESTING in Primary Care, Rockville, MD: SAMHSA; 2012. Technical Assistance Publication (TAP) 32, HHS publication (SMA) 12-4668.Agency Medical Directors Group. Interagency guideline on opioid dosing for chronic non-cancer pain: An educational aid to improve care and safety with opioid therapy 2010 Update.Melanson Stacy EF, Baskin LB. Interpretation and utility of drug of abuse immunoassays: lessons from laboratory drug testing surveys. Arch Pathol Lab Med. 2010;134:736-739.Standridge JB, Adams SM. Urine drug screening: a valuable office procedure. American Family Physician. 2010;81(5):635-640.American Medical Association, CPT 2021 Professional Edition, 26 November 2020, ISBN: 1640160493.Drug Enforcement Administration, U.S. Department of Justice, Drugs of Abuse: A DEA Resource Guide, 2020 Edition.Jannetto PJ, Bratanow NC, Clark WA, et al. Executive Summary: American Association of Clinical Chemistry Laboratory Medicine Practice GuidelineUsing Clinical Laboratory Tests to Monitor Drug Therapy in Pain Management Patients. The Journal of Applied Laboratory Medicine. 2018;2(4):489526.https://doi.org/10.1373/jalm.2017.023341AMA Report 2 of the Council on Science and Public Health (I-08): Improving Medical Practice and Patient/Family Education to Reverse the Epidemic of Nonmedical Prescription Drug Use and Addiction.American Academy of Pain Medicine, Guideline Statement, Use of Opioids for the Treatment of Chronic Pain, March 2013.Passik SD, Kirsh KL, Casper D. Addiction-related assessment tools and pain management: instruments for screening, treatment planning and monitoring compliance. Pain Med. 2008;9:S145-S166.