Medicare Part B local coverage determination (LCD) comment summary

LCD Number

G0430

Contractor Name

First Coast Service Options, Inc.

Contractor Number

09102 - Florida
09202 - Puerto Rico
09302 - U.S. Virgin Islands

Contractor Type

MAC Part B

LCD Title

Qualitative Drug Screening

AMA CPT Copyright Statement

CPT codes, descriptions, and other data only are copyright 2009 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

Start Date of Comment Period:

09/24/2009

End Date of Comment Period:

11/07/2009

Comments received:

Comment #1: The proposed indications of medical necessity and supporting ICD-9-CM codes will negatively impact patient care because they do not address some of the most common underlying causes of pain. Additionally, this will compromise clinician’s ability to extend appropriate coverage in accordance with current medical guidelines and state medical board policy to pain patients requiring management with controlled substances. For these reasons it is recommended that the medical necessity be expanded to include the following ICD-9-CM codes: 338.28 (Other chronic postoperative pain), 338.29 (Other chronic pain), 346.81 (Other forms of migraine with intractable migraine), 346.9 (Unspecified migraine without mention of intractable migraine), 350.0 (Unspecified trigeminal nerve disorder), 350.1 (Trigeminal neuralgia), 357.4 (Polyneuropathy in other diseases classified elsewhere), 714.9 (Unspecified inflammatory polyarthropathy), 715.0 (Generalized osteoarthrosis, unspecified site), 715.09 (generalized osteoarthrosis, involving multiple sites), 719.41 (Pain in joint, shoulder region), 719.45 (Pain in joint, pelvic region and thigh),) 719.46(Pain in joint, lower leg), 721.3 (Lumbosacral spondylosis without myelopathy), 722.4 (Degeneration of cervical intervertebral disc), 722.52 (Degeneration of lumbar or lumbosacral intervertebral disc), 722.6 (Degeneration of intervertebral disc, site unspecified), 722.81 (Post-laminectomy syndrome, cervical) , 722.83 (Post-laminectomy syndrome, lumbar ), 723.1 (Cervicalgia), 723.4 (Brachia neuritis or ridiculitis 724.2 (Lumbago), (724.3) Sciatica 724.4 (Thoracic or lumbosacral neuritis or ridiculitis, 724.1 (Pain in thoracic spine),), 724.5 (Unspecified backache), 724.9 (Other unspecified back disorder), unspecified 729.1 (Unspecified myalgia and myositis),729.2 (Unspecified neuralgia, neuritis, and radiculitis, 729.5 (Pain in soft tissues of limb).

Contractor response: This is a qualitative drug screening LCD. Pain diagnoses do not adequately represent diagnoses that would identify high pre-test probability of non-adherence to a prescribed drug regimen or of drug use, abuse, overdose or poisoning. When the requirements described in the Indications section of this draft LCD are met, the ICD-9-CM codes that support medical necessity with the addition of ICD-9-CM code V15.81 (Noncompliance with medical treatment), should adequately represent when qualitative drug screening would be considered medically reasonable and necessary.

Comment #2: Urine drug testing/screening should be allowed as part of a controlled substance compliance monitoring program within practices that treat patients who suffer from chronic pain. This in office testing is absolutely crucial to the safe and judicious practice of pain management. It was proposed that random, routine urine toxicology testing be allowed to avoid improper use of drugs, thus allowing for early recognition of patterns of inappropriate drug use or diversion. Coverage should include urine drug screening at the initiation of care and up to four times per year for the purpose of monitoring pain medication therapy.

Contractor response: Qualitative drug screening is an allowable service for the management of chronic pain patients when there is a high pre-test probability of non-adherence to the prescribed drug regimen. The current Medicare benefit does not allow for screening protocols.

Comment #3: The list of indications in the draft qualitative drug screening LCD is not comprehensive enough, Disallowing payment of qualitative drug screening as part of a physician’s protocol for treatment will very likely lead to the unintended consequences of increased diversion of prescription opioids and decreased numbers of physicians willing to treat Medicare patients who are legitimately in chronic pain.

Contractor response: The final LCD was revised to allow for patients in which there is a high pre-test suspicion of non-adherence to a prescribed drug regimen or when there is a high suspicion of other drug use. Services for patients who do not exhibit one of the indications as stated in the LCD could be considered routine screening. The last two bullets under the indications section of the LCD (with minor revisions) address the management of patients within the current Medicare benefit. Currently, the Medicare benefit does not include protocols for routine screening.

Comment #4: Please consider amending the following language: “Medicare will consider performance of a qualitative drug screening medically reasonable and necessary when a patient presents with suspected drug overdose and one or more of the following conditions” to “Medicare will consider performance of a qualitative drug screen medically reasonable and necessary when a patient presents with suspected drug overdose (or drug misuse) and one or more of the following conditions”.

Contractor response: The final LCD was revised to reflect the medically reasonable and necessary indications for CPT/HCPCS codes describing qualitative drug screening.