ICD-10 F45.42 is officially defined as "Pain disorder with related psychological factors." code F45.42 is referenced in 3 tracked payer policy changes from Missouri Medicaid (MO HealthNet), Excellus BlueCross BlueShield, and 1 other payer. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code F45.42 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Effective July 1, 2026, MO HealthNet will discontinue coverage for physical therapy, chiropractic therapy, and acupuncture services under the Complementary Health and Alternative to Chronic Pain Management Program. All pre-certifications for these services approved beyond July 1, 2026 will be closed as of June 30, 2026. Cognitive Behavioral Therapy (CBT) remains covered with specific code and precertification requirements.
Excellus BlueCross BlueShield policy 2.02.50 for urine drug testing considers in-office or point-of-care presumptive immunoassay urine drug testing medically appropriate for outpatient pain management and for outpatient substance use treatment, both for baseline screening and for ongoing monitoring at a frequency matched to the patient's risk. Definitive urine drug testing is considered medically appropriate when presumptive testing cannot identify a specific substance or drug, when a definitive drug concentration is needed to guide management, to rule out an error as the cause of a qualitative result, or as part of a differential assessment of medication efficacy, side effects, or drug-drug interactions. The October 22, 2026 version is recorded as an annual review with the policy intent unchanged.
Blue Cross Blue Shield Association policy 2.04.98 added CPT 0603U, a presumptive drug assay of 77 drugs or metabolites in urine by LC-MS/MS reported as positive or negative, which the code table lists as new as of 01/01/2026 and as investigational. The policy considers routine presumptive urine drug testing not medically necessary in chronic non-cancer pain management and substance use disorder treatment, and considers hair drug testing and oral fluid drug testing investigational in both settings. Presumptive urine drug testing is medically necessary only for the baseline screening and monitoring frequencies the policy lists for each setting.
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