Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1.    Allergy testing requires preauthorization except for the following:

a.    Percutaneous (scratch, prick or puncture) testing

b.    Intradermal testing

c.    Patch testing up to first 80 units.

d.    In vitro testing (certain types of blood tests) is covered when performed by Allergist, for one set, up to 70 tests; additional in vitro testing requires pre-authorization.

2.    Other allergy tests that require preauthorization include patch testing for more than 80 units, intradermal dilution testing, oral challenge testing and pulmonary function testing.

3.    For pulmonary function testing, please refer to BI542.

4.    Tests that are considered Experimental and Investigational are not covered and are listed under the Limits section.

For pulmonary function testing, please refer to BI542.

1)    The following forms of allergy testing are considered medically necessary and do not require pre-authorization:

         A)    Percutaneous (scratch, prick or puncture) skin testing (95004) has a maximum limit of 70 units per 12 months and is considered medically necessary when IgE-mediated reactions occur to any of the following:

                        i.    Inhalants; or

                      ii.    Foods; or

                     iii.    Hymenoptera (stinging insects); or

                     iv.    Specific drugs (penicillin’s and macromolecular agents).

         B)    Intradermal (Intracutaneous) allergy testing (95024, 95028) is performed when percutaneous tests are negative. Intradermal allergy testing has a maximum combined limit of 40 units per 12 months; any additional units require pre-authorization. Intradermal allergy testing is considered medically necessary when IgE-mediated reactions occur to any of the following:

                        i.    Inhalants; or

                      ii.    Foods; or

                     iii.    Hymenoptera (stinging insects); or

                     iv.    Specific drugs (penicillin’s and macromolecular agents).

         C)    Allergen Specific IgE (in vitro) Testing (86003 – 86008) requires evaluation by an Immunologist or Dermatologist and has a limit of up to 70 tests per year; any additional tests require pre-authorization. Allergen specific testing is considered medically necessary under the following guidelines:

i.    When percutaneous testing of IgE-mediated allergies cannot be done for:

a.    Inhalant allergy; or

b.    Food allergy;

1.    Due to any of the following reasons:

·      Member has severe Dermatographism, ichthyosis, or generalized eczema; or

·      Member is unable to discontinue antihistamines but is in need of allergy testing; or

·      Difficulty in testing uncooperative members (e.g., small children or individuals with mental or physical impairments); or

·      When clinical history suggests an unusually greater risk of anaphylaxis from skin testing than usual; or

·      Direct skin testing is inconclusive.

ii.    Also as an alternative to percutaneous testing for:

a.    The evaluation of cross-reactivity between insect venoms; or

b.    As adjunctive laboratory tests for disease activity of allergic bronchopulmonary aspergillosis (ABPA) and certain parasitic diseases.

         D)    Skin Patch Testing (95044) for diagnosing contact allergic dermatitis. The first 80 units are covered without pre-authorization; any additional units require pre-authorization.

         E)     Skin Endpoint Titration (SET) or Intradermal Dilutional testing (IDDT) (95017, 95018, 95027) is covered for a cumulative total of 80 units per calendar year for determining the starting dose for immunotherapy for members highly allergic to:

                        i.    Inhalant allergy (95027); or

                      ii.    Hymenoptera venom allergy (95017); or

                     iii.    Drugs/biological allergy (95018).

 It is inappropriate to use SET or IDDT (95027) in place of skin testing and it is not   eligible for benefits unless skin testing has been performed.

2)    The following tests require pre-authorization:

A)   Photo Patch Testing (95052) for diagnosing photo allergy (e.g., photo-allergic contact dermatitis to be requested by an Allergist or Dermatologist)

B)   Photo Tests (95056) for evaluating photosensitivity disorders, to be requested by an Allergist or Dermatologist.

C)   Exercise Challenge Testing (94617, 94618) for exercise-induced bronchospasm, to be requested by Allergist or Pulmonologist.

D)   Bronchial Challenge Test (95070 – 95071) for testing with methacholine, histamine or antigens in defining asthma or airway hyperactivity when any of the following conditions are met:

                        i.    Asthma is a serious possibility and spirometry performed before and after administration of a bronchodilator, have not established or eliminated the diagnosis; or

                      ii.    To identify new allergens for which skin or blood testing has not been validated;  or

                     iii.    When skin testing is unreliable; AND

                     iv.    When requested by a Pulmonologist or Allergist.

E)   Ingestion (Oral) Challenge Test (95076 – 95079) for any of the following:

i.      Food or other substances (i.e., Metabisulfite); or

ii.   Drugs when all of the following are met:

a)    History of allergy to a particular drug; and

b)    Treatment with that drug class is essential; and

c)    There is no effective alternative drug; and

d)    Requested by an Allergist.

F)    Peanut allergen-specific quantitative assessment (0178U) for documented severe anaphylactic reaction to minimal peanut exposure.

Codes Used In This BI:

The following tests are considered experimental and investigational as they have not been proven to be effective:

A.    Exhaled nitric oxide measurement.

B.    ALCAT test

C.    IgG RAST/ELISA Testing

D.    Candidiasis test

E.    Chlorinated pesticides (serum)

F.    Complement (total or components); (may be appropriate in autoimmune disorders, complement component deficiencies, hereditary angioedema, vasculitis)

G.   C-reactive protein (may be appropriate in inflammatory diseases)

H.    Cytotoxic food testing (Bryans Test, ACT)

I.      Electrodermal acupuncture

J.     ELISA/ACT

K.    Food immune complex assays (FICA)

L.     Immune complex assay (may be appropriate in autoimmune disorders, systemic lupus erythematosus, vasculitis)

M.   Leukocyte histamine release test

N.    Lymphocytes (B or T subsets); (may be appropriate for collagen vascular disease, immune deficiency syndromes, leukemia, lymphomas)

O.   Mediator release test (MRT)

P.    Testing for multiple chemical sensitivity syndrome (a.k.a., idiopathic environmental intolerance (IEI), clinical ecological illness, clinical ecology, environmental illness, chemical AIDS, environmental/chemical hypersensitivity disease, total allergy syndrome, cerebral allergy, 20th century disease)

Q.   Muscle strength testing or measurement (kinesiology) after allergen ingestion

R.    Ophthalmic mucous membrane tests/conjunctival challenge tests

S.    Direct nasal mucous membrane testing/provocative nasal test

T.    Prausnitz-Kustner or P-K testing - passive cutaneous transfer test

U.    Provocation-neutralization testing (Rinkel Test) either subcutaneously or sublingually

V.    Pulse test (pulse response test, Reaginic pulse test)

W.  Rebuck skin window test

X.    Sublingual provocative neutralization testing and treatment with hormones

Y.    Venom blocking antibodies

Z.    Volatile chemical panels (blood testing for chemicals).

1.    American Academy of Allergy, Asthma and Immunology. What is allergy testing? Available at http://www.aaaai.org/patients/publicedmat/tips/whatisallergytesting.stm

2.    Leow YH, Goh CL. Contact allergy in Singapore. Asian Pac J Allergy Immunol. 1999; 17(3):207-217.

3.    Mark KA, Brancaccio RR, Soter NA, et al. Allergic contact and photo allergic contact dermatitis to plant and pesticide allergens. Arch Dermatol. 1999; 135(1):67-70.

4.    Oliveira HS, Goncalo M, Figueiredo AC. Photosensitivity to lomefloxacin. A clinical and photo biological study. Photodermatol Photoimmunol Photomed. 2000; 16(3):116-120.

5.    Lane AP, Pine HS, Pillsbury HC 3rd. Allergy testing and immunotherapy in an academic otolaryngology practice: a 20-year review. Otolaryngol Head Neck Surg. 2001; 124(1):9-15.

6.    Parker F. Skin diseases of general importance. In: Cecil Textbook of Medicine. 21st ed. L Goldman, JC Bennett, eds. Philadelphia, PA: W.B. Saunders Co; 2000: 2277, 2295-2296.

7.    Parker F. Examination of the skin and an approach to diagnosing skin disease. In: Cecil Textbook of Medicine. 21st ed. L Goldman, JC Bennett, eds. Philadelphia, PA: W.B. Saunders Co; 2000: 2271.

8.    No authors listed. American Gastroenterological Association medical position statement: Guidelines for the evaluation of food allergies. Gastroenterology. 2001; 120(4):1023-1025.

9.    Teuber SS, Porch-Curren C. Unproved diagnostic and therapeutic approaches to food allergy and intolerance. Curr Opin Allergy Clin Immunol. 2003; 3(3):217-221.

10. Somerville M. Immunotherapy for seasonal rhinitis, asthma and bee sting venom allergy. Bazian Ltd., eds. London, UK: Wessex Institute for Health Research and Development, University of Southampton; 2002.

11. BlueCross BlueShield Association (BCBSA) Technology Evaluation Center. Serial Endpoint Testing for the Diagnosis and Treatment of Allergic Disorders July 2002. Available at: http://www.bcbs.com/tec/vol17/17_06.html

12. Arkansas Blue Cross Blue Shield. Coverage Policy Manual, RAST Tests. Available at: http://www.arkbluecross.com/members/ex_report.asp?ID=1997188

13. Senna G, Passalacqua G, Lombardi C, Antonicelli L. Position paper: Controversial and unproven diagnostic procedures for food allergy. Allergy Immunol (Paris). 2004; 36(4):139-145.

14. Klein R, Schwenk M, Heinrich-Ramm R, Templeton DM. Diagnostic relevance of the lymphocyte transformation test for sensitization to beryllium and other metals. IUPAC Technical Report. Pure Appl Chem. 2004; 76(6):1269-1281.

15. Barna BP, Culver DA, Yen-Lieberman B, et al. Clinical application of beryllium lymphocyte proliferation testing. Clin Diagnose Lab Immunol. 2003; 10(6):990-994.

Addendum:

1)    Effective 04/01/2017: Specified coverage limits for percutaneous and intracutaneous allergy testing. Clarified under limits that IgG testing (86001) is considered experimental and investigational. Added coverage for Bronchial Challenge testing with pre-authorization.

Removed CPT codes 95010 & 95015 from policy. These codes were deleted 1/1/13 & replaced with 95017 & 95018. Also added the following CPT codes corresponding with Bronchial Challenge Testing coverage:  94070, 94150, 94200, 94350, 94360, 94620, 94621, 94680, 94681, 94690, 94720, & 94770. 

Retroactive to 01/01/2017 – No PA needed for the following CPT codes: 94010, 94060, and 94375.

2)    Effective 09/01/2017: Removed CPT codes for PFT from BI and added the following statement: “For pulmonary function testing, please refer to BI542. Also updated “Codes Used in This BI” section to reflect updated changes.

3)    Effective 11/01/2017: Skin Patch Testing: first 80 units is covered without prior authorization. Additional units require pre-authorization.

4)    Effective 3/8/2018: Added new code for 2018.

5)    Effective 10/01/2018: 95024 and 95028 have a maximum combined limit of 40 units per 12 months. Any additional units require prior authorization. Removed PA requirements for 95017, 95018 and 95027 (Skin serial endpoint titration (SET) for determination of a safe starting dose for testing or immunotherapy): are covered for a cumulative total of 80 units per calendar year. Some types of allergy testing require evaluation by specialists.

6)    Effective 02/01/2019: Updated codes in Medical Policy Statement section to align with system configuration.

7)    Effective 07/01/2020: Added new code (0178U) with pre-authorization.

8)    Deleted code 95071 (eff 01-01-2021), updated revised code 95070 (eff 01-01-2021) and added codes 94617 and 94618 that were in the medical statement requiring PA and added to search box as well as description of codes in the codes used in this BI.

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.