AmeriHealth has created a policy to communicate the medical necessity
criteria for therapeutic drug monitoring (TDM) of antidepressants,
antipsychotics, and antiepileptic medications. Medical Policy #06.02.55:
Therapeutic Drug Monitoring for Antidepressants, Antipsychotics, or
Antiepileptics was posted as a Notification on March 8, 2017, and goes into
effect April 7, 2017.
Medically necessary criteria
TDM for antidepressants, antipsychotics, and antiepileptic medications is
considered medically necessary, and, therefore, covered for any of the
following reasons when a plan is in place to use the test findings
clinically:
- dose optimization after initial prescription or dose change;
- suspected complete or partial non-adherence or non-compliance to prescribed
medication;
- lack of clinical improvement under recommended dose;
- clinical improvement under recommended dose but with adverse effects;
- initiation of combination therapy with a drug known for its interaction
potential or suspected drug interaction;
- relapse prevention under maintenance treatment.
Coverage limits
When the above criteria are met, TDM is considered medically necessary, and,
therefore, covered for the following number of units:
- Antidepressants: A combined maximum of up to 15 units of
tests per calendar year.
- – CPT® codes: 80332, 80333, 80334, 80335, 80336, 80337,
80338
- Antiepileptics: A combined maximum of up to 15 units of
tests per calendar year.
- – CPT codes: 80339, 80340, 80341, 80355, 80366, 80156, 80157, 80164,
80165, 80168, 80171, 80175, 80177, 80183,
80184, 80185 , 80186, 80188, 80199, 80201, 80203
- Antipsychotics: A combined maximum of up to 15 units of
tests per calendar year.
- – CPT codes: 80342, 80343, 80344, 80159, 80173, 80178
Specimen validity/adulteration testing is not eligible for separate
reimbursement, as this is considered part of the laboratory quality control
practice.
More information
To view the Notifications for these policies, visit our Medical Policy Portal and select Accept and Go to
Medical Policy Online. Then select Commercial under Active
Notifications.
If you have any questions, please contact your Provider Partnership
Associate or Network Coordinator.
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