Policy Implementation/Update Information
7/79 Original Policy
5/81 Reaffirmed
6/83 Reaffirmed
6/84 Reaffirmed
7/87 Evaluated: Investigational for provocative testing for food allergies. Eligible for coverage for serial dilution endpoint titration (Rinkel).
5/90 Evaluated: Eligible for coverage for specific IgE in vitro tests (RAST, MAST, FAST, ELISA) for inhalant and food allergens. Eligible for coverage for insect stings and other allergens when direct skin testing is not possible.
8/90 Revised: Total serum IgE concentration indications
1/93 Reviewed: PCP Physician Advisory Group (Local))
11/94 Reviewed: PCP Physician Advisory Group (Local)
11/95 Reviewed: PCP Physician Advisory Group (Local)
12/96 Revised: Added Rush Immunotherapy as investigational
3/99 Revised: Deleted the comment, "Rush" or "Cluster" immunotherapy. This type of immunotherapy is not considered medically necessary when compared with standard immunotherapy. This comment has been added to the Allergy Immunotherapy (95115.MED) policy and will be reviewed on an Individual Consideration basis.
5/99 Revised based on feedback from the MPAG. Nasal Challenge moved to investigational as it is obsolete. SDET or Rinkel is considered investigational.
8/99 Reformatted, Medical Term Definitions added.
7/00 Specialty Matched Consultant Advisory Panel. No changes to policy.
9/00 System coding changes.
10/00 Specialty Matched Consultant Advisory Panel. Criteria clarification of Specific IgE In Vitro Testing under When Allergy Testing is covered section. Four criteria applied to both inhalant allergens and insect sting and other allergens. Medical Policy Advisory Group review. Approved. No further changes to criteria.
02/01 Specialty Matched Consultant Advisory Panel review. Added additional information related to SDET or classic Rinkle method.
6/01 Serial Dilution Endpoint Titration is now listed as a covered service.
9/01 Codes 86001, 86003, and 86005 added to Billing/Coding section. Changed statement in Billing/Coding section to state, "Reimbursement for Specific IgE In Vitro Testing and Serial Dilution Endpoint Titration is based on the number of anitgens tested, not the number of dilutions/injections performed." System coding changes.
7/02 Specialty Matched Consultant Advisory Panel review. Under "When Allergy Testing is Covered" 3.a.ii. and 3.b.ii. revised to state "If direct skin testing is impossible such as in young children less than four years of age;". Under "When Allergy Testing is not Covered" added Serum IgG levels, as part of allergy evaluation
09/02 System coding changes.
See Also: Allergy Immunotherapy.
10/02 System coding changes. Clarified excessive number of patch tests to be greater than 30.
1/03 Disclaimer added. Added "such as recalcitrant contact dermatitis" to clarify when more than 30 patch tests may be allowed on an IC basis.
10/03 Benefits Application and Billing/Coding sections revised.
11/03 Acronym for American Academy of Allergy, Asthma, and Immunology corrected from AAAI to AAAAI.
10/14/04 Specialty Matched Consultant Advisory Panel review 7/23/04. Under "When Covered": 1.a added "Rarely are more than 40 percutaneous tests required in a three year period."; 1.b added "Rarely are more than 20 intracutaneous tests required in a three year period."; added photo-patch test and double-blind food challenge test; added "or for consideration of Xolair administration in patients with moderate to severe asthma." to #5. Under "When Not Covered", added Conjunctival Challenge Testing as investigational. Sources added. Notice given 10/14/04. Effective date 12/23/04.
5/7/07 Description section revised to explain in vivo and in vitro testing. Under "When Covered", #1.a. removed statement "Rarely are more than 40 percutaneous tests required in a three year period."; #1.b. removed statement "Rarely are more than 20 intracutaneous tests required in a three year period."; added 1.c. "The evaluation of inhalant allergy may require up to 70 prick/puncture tests followed by up to 40 intradermal tests, which are ordinarily performed when prick/puncture and/or intradermal tests are negative. Under special circumstances and in certain geographic areas, a greater number of prick/puncture and/or intradermal tests may be appropriate. However, in many parts of the country and probably in most cases, fewer tests are required."; #4. "Specific IgE In Vitro Testing: clarified that the testing should only be done when the listed criteria precludes the use of direct skin testing, that initial diagnostic screen is limited to 36 allergen specific antibodies, additional testing will require individual review; #8. Serial Dilution Endpoint Titration (SDET) now reads "Also known as skin endpoint titration (SET), intradermal dilutional testing (IDT), Serial endpoint titration. Allergy testing using this method is similar to conventional intradermal testing differing only in the number of dilutions of allergen administered. SDET is eligible as a variant of conventional intradermal skin testing." Under "When not Covered", additional information provided for: nasal challenge test, leukocyte histamine release test, Rebuck skin window test, passive transfer of P-X, and provocative testing. Under "Billing and Coding", revised to have same information as indicated in the "When Covered" section re: number of tests. Reference sources and Definitions added. (pmo)
6/18/07 Under "When Covered", 1.c. removed error- "...which are ordinarily performed when prick/puncture and/or intradermal tests are negative. Under "When not Covered", added Mediator Release Test (MRT) as investigational. "The MRT has primarily been used to detect intolerance to foods and additives in patients with irritable bowel syndrome (IBS). It has also been promoted for use in patients with, but not limited to: chronic fatigue syndrome, migraine headaches, rheumatologic disorders, and dermatologic conditions. The results of the MRT have been used to design a patient-specific diet." Reason it is investigational: "There are no studies of MRT reported in peer-reviewed published medical literature that demonstrate improvements in clinical outcomes by incorporating the MRT and associated dietary modifications into the clinical management of patients with these conditions." Reference source added. Notification given 6/18/07. Effective 8/27/07. (pmo)
8/27/07 Under "Billing/Coding section, added CPT codes 83516, 83518, 83519, 83520; removed deleted CPT code 95078. (pmo)
2/25/08 Under "When Covered" 2. Patch Testing-Additional information provided. Coverage for initial number of patch tests increased to 35 tests. Clarified indications for more comprehensive patch testing. Added CPT code 86343 to Billing/Coding section. Reference sources added. Under "Policy Implementation/Update Information", date 5/2/07, removed "added mediator release test as investigational" and "added CPT codes 83516, 83518, 83519, 83520". The mediator release test information was actually added to the policy and listed in the 6/18/07 implementation date. The CPT codes were actually added with the 8/27/07 update and are now listed with the 8/27/07 implementation date. (pmo)
8/25/08 References updated. Specialty Matched Consultant Advisory Panel review 7/14/08. No change to policy statement. (adn)
10/12/09 Description of Item 8 (Serial Dilution Endpoint Titration) in the When Allergy Testing is Covered section was reworded. Corrected typo regarding the number of Patch Testing (Item 2 in the When Allergy Testing is Covered section). Greater than 35 patch tests will be reviewed by individual consideration. Documentation of medical necessity for over 35 tests will be necessary. (adn)
6/22/10 Policy Number(s) removed. (amw)
12/21/10 Specialty Matched Consultant Advisory Panel review 11/2010. References updated. Added additional information regarding Serial Endpoint Titration. (mco)
12/20/11 Specialty Matched Consultant Advisory Panel review 11/2011. Added “ImmunoCAP” as a Specific IgE In Vitro Test. Added the following tests to the “When not Covered” table: “Antigen Leukocyte Cellular Antibody (ALCAT) Automated Food Allergy Testing. There is insufficient evidence in the published peer-reviewed scientific literature to support the use of this testing in the diagnosis or management of allergic disease.” “In Vitro Metal Allergy Testing. There is insufficient evidence that in vitro metal allergy testing improves patient management decisions or health outcomes for total joint replacement patients. No national organizations have issued recommendations regarding in vitro metal allergy testing and orthopedic implants.” References updated. Added CPT code 86353 to “Billing/Coding” section. References updated. Notice given on 12/20/11 for effective date 03/20/12. (mco)
6/12/12 Allergy patch testing limitation increased from 36 to 42 units. Greater than 42 patch tests will be reviewed and documentation of medical necessity will be required. (mco)
1/1/13 Specialty Matched Consultant Advisory Panel review 11/2012. References updated. Deleted CPT codes 95010, 95015, 95075 and added 95017, 95018, 95076, 95079 to Billing/Coding section. (mco)
7/1/13 Revised “When Covered” section for Patch Testing as follows: “More comprehensive patch testing (greater than 42 patch tests) may be considered medically necessary when both a.) and b.) are met: a. The patient has persistent allergic contact dermatitis (ACD) after being previously evaluated and treated (including 6 weeks of avoidance of any allergens that were positive on initial patch testing, and use of topical steroid products if appropriate) OR Patient has any of the following: --At least 8 weeks of dermatitis without resolution with treatment, --Has a dermatitis that may be implanted device-related, --Is undergoing pre-testing for medical or dental device placement, --Requires extensive patch testing to determine if persistent dermatitis is allergic contact dermatitis, --Has seen at least one other physician who has requested specialty patch testing; AND b. The dermatitis interferes with the patient’s normal activities of daily living, such as occupational or work activities (use of hands), sleep patterns (due to itching), bathing or social interactions.” References updated. Medical Director review 6/2013. (mco)
12/10/13 Specialty Matched Consultant Advisory Panel review 11/2013. References updated. Medical Director review 11/2013. Added the following statements to the “When Covered” section: “Repeat Allergy Skin Testing-a.) Repeat skin testing with multiple antigens is medically necessary for children who are Initially sensitive to food and indoor environmental exposures but later develop pollen and outdoor mold sensitivities. b.) Repeat skin testing may be considered medically necessary for adults who: i.)develop dramatic change of symptoms, ii)have received three to five years of venom immunotherapy, .iii.)are being evaluated for newly discovered purified or standardized allergens.” Added the following statement to the “When not Covered” section: “Repeat skin testing with multiple antigens is considered not medically necessary when criteria in the covered section are not met.” Policy noticed 12/10/13 for effective date 02/11/14. (mco)
12/9/14 References updated. Specialty Matched Consultant Advisory Panel review 11/2014. Medical Director review 11/2014. (td)
12/30/15 When Covered section 9. b. revised to state, “Repeat skin testing may be considered medically necessary for adults who: i. have food allergy and require reevaluation to examine for resolution of their food allergy or; have received three to five years of venom immunotherapy and require reevaluation for resolution of their venom allergy or; develop increased atopic symptoms suggesting new sensitizations.” References updated. Specialty Matched Consultant Advisory Panel review 11/2015. Medical Director review 11/2015. (td)
12/30/16 Specialty Matched Consultant Advisory Panel review 11/2016. Medical Director review 11/2016. (jd)
10/27/17 Added “Maximum Units of Service” to list of Related Policies. Minor revision to When Covered section; removed the following statement from paragraph below item 4b – ”Additional testing beyond this number will require individual review for medical necessity.” No change to policy intent. (jd)
12/15/17 Code 86008 added to code section, effective 1/1/18. Specialty Matched Consultant Advisory Panel review 11/2017. Medical Director review 11/2017.(jd)
3/9/18 When Covered section of policy revised below section 4b; limiting diagnostic screening from 36 to 20 allergen specific antibodies. References updated. Policy noticed 3/9/18, effective 5/11/18. Specialty Matched Consultant Advisory Panel review 2/2018. Medical Director review. (jd)
5/25/18 Added Pediatric Allergy Solution Macroarray Test to bottom of the allergy testing table under the section: When Allergy Testing is not covered. References updated. Medical Director review 5/2018. (jd)
12/31/18 References updated. Specialty Matched Consultant Advisory Panel review 11/2018. Medical Director review 11/2018. (jd)
For the policy titled: Allergy Skin and Challenge Testing
4/1/19 Added Allergen Testing to Related Policies section and referenced this policy for in vitro testing in the Description section. Revised title throughout policy. Removed IgE and other in vitro related criteria from both the When Covered and When Not Covered sections, along with the policy guidelines. Updated Billing/Coding section. Medical Director review 4/2019.(jd)
12/10/19 Specialty Matched Consultant Advisory Panel review 11/2019. Medical Director review 11/2019. (jd)
12/8/20 References updated. Specialty Matched Consultant Advisory Panel review 11/2020. Medical Director review 11/2020. (jd)
11/30/21 Specialty Matched Consultant Advisory Panel review 11/2021. Medical Director review 11/2021. (jd)
11/29/22 References updated. Removed code 95071 from Billing/Coding section. Specialty Matched Consultant Advisory Panel review 11/2022. Medical Director review 11/2022. (tm)
12/29/23 When Covered section edited for clarity, no change to policy statement. References updated. Specialty Matched Consultant Advisory Panel review 11/2023. Medical Director review 11/2023. (tm)
12/17/24 References updated. Specialty Matched Consultant Advisory Panel review 11/2024. Medical Director review 11/2024. (tm)
