This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions


This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to persons covered by the Mississippi Children's Health Insurance Program, Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions


This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to persons covered by the Mississippi Children's Health Insurance Program, Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions

Medical Policy Search
Printer Friendly Version Allergy Testing

Allergy Testing

 

DESCRIPTION

 Allergic or hypersensitivity disorders may be manifested by generalized systemic reactions as well as localized reactions in any organ system of the body. The reactions may be acute, subacute or chronic, immediate or delayed, and may be caused by numerous offending agents; e.g., pollen, molds, dust, mites, animal dander, stinging insect venoms, foods and drugs.

The optimum management of the allergic patient should include a careful history and physical examination and may include confirming the cause of allergic reaction by information from some of the testing methods outlined below. Once the agent is identified, treatment is provided by avoidance, medication or immunotherapy.

The following allergy tests are available in the diagnosis of the allergic patient:

  1. Direct Skin Test

    • Percutaneous (scratch, prick or puncture)
    • Intracutaneous (intradermal)

  2. Patch Test (Application Test)

    This test modality identifies allergens causing contact dermatitis. The suspected allergens are applied to the patient's back under dressings and allowed to remain in contact with the skin for 48 hours. The area is then examined for evidence of delayed hypersensitivity reactions.

  3. Photo Patch Test

    This test reflects contact photosensitization. A patch of skin is applied with the suspected sensitizer for 48 hours. If no reaction occurs, the area is exposed to a dose of ultraviolet light sufficient to produce inflammatory redness of the skin. If the test is positive, a more severe reaction develops at the patch site than on surrounding skin.

  4. Specific IgE In Vitro Tests:

    • Radioallergosorbent Tests (RAST)
    • Multiple Radioallergosorbent Tests (MAST)
    • Fluorescent Allergosorbent Test (FAST)
    • Enzyme-linked Immunosorbent Assay (ELISA)

These tests detect antigen-specific IgE antibodies in the patient's serum.

  1. Total Serum IgE Concentration

    This testing modality is not indicated in most allergic patients, but may be indicated for those patients suspected of having allergic bronchopulmonary aspergillosis, immune deficiency disease characterized by increased IgE levels; (e.g., Wiskott-Aldrich syndrome, hyper-IgE staphylococcal abscess syndrome), IgE myeloma or pemphigoid.

  2. Certain Bronchial Challenge Tests

    Histamine or methacholine is used to perform this test when it is necessary to determine if the patient has hyper-responsive airways. Volatile chemicals are used to perform the test when the allergy is encountered in an occupational setting.

  3. Double Blind Food Challenge Test

    With this test, the patient ingests the food to which sensitivity is suspected. Both the patient and the physician are "blinded." This is usually done at home, but in some instances of extreme suspected hypersensitivity, it may be performed in the office setting.

    8. Serial Endpoint Testing (SET)

Serial endpoint testing (SET) is a form of intradermal skin testing that uses increasing doses of antigen to determine the concentration at which the reaction changes from negative to positive (the "endpoint"). The test has been used for diagnosing allergic disorders, and is a potential alternative to other diagnostic tests such as skin prick testing or in vitro testing for this purpose. Also SET has been used to guide the initiation of immunotherapy, by using the endpoint dilution as the starting antigen dose. 

 

POLICY

 The following allergy tests are considered medically necessary in the diagnosis of the allergic patient:
  1. Direct Skin Tests

    The number of tests required may vary widely from patient to patient, depending upon the patient's history. There is a limit of 50 percutaneous and up to 20 intracutaneous skin tests per day.
    A test is defined per antigen, not per injection of antigen (added 4/28/00). 
  2. Patch Test (Application Test)   
  3. Photo Patch Test   
  4. Specific IgE In Vitro Tests:
    • Radioallergosorbent Tests (RAST)
    • Multiple Radioallergosorbent Tests (MAST)
    • Fluorescent Allergosorbent Test (FAST)
    • Enzyme-linked Immunosorbent Assay (ELISA)

These tests detect antigen-specific IgE antibodies in the patient's serum. They are considered medically necessary only once when testing for: inhalant allergens, (pollens, molds, dust, mites, animal danders), foods, insect stings, and other allergens such as drugs, when direct skin testing is impossible due to extensive dermatitis or marked dermatographism.  Also appropriate in children less than four years of age or if the patient's symptoms are life threatening (ie, suspected peanut allergy).  

  1. Total Serum IgE Concentration  
  2. Certain Bronchial Challenge Tests
    If dust, ragweed or other common allergens are the suspected cause of the problem, this test is not medically necessary, since skin tests can be used in these situations.
  3. Double Blind Food Challenge Test

    This is usually done at home, but in some instances of extreme suspected hypersensitivity, it may be performed in the office setting. In the latter case, this is considered to be part of the office visit and no additional benefits are provided.  
  4. Serial Endpoint Testing (SET)

Serial endpoint testing (SET) may be considered medically necessary for the determination of a safe starting dose for testing or immunotherapy when there is potential for the specific allergen in question to produce a severe systemic allergic reaction or anaphylaxis (i.e., chemicals, drugs, bee venom or peanuts).

Repeat skin testing with multiple antigens is not medically necessary unless there is clear documentation of rare and extraordinary circumstances such as:

In Children:

  • Initially sensitive to food and indoor environmental exposures but later develop pollen and outdoor mold sensitivities.

In Adults:

  • Dramatic change of symptoms
  • Three to five years of venom immunotherapy
  • Evaluation of newly discovered purified or standardized allergens

The following allergy tests are considered investigational, and not covered:

  1. Provocative tests for food or food additive allergies
  2. Nasal challenge test
  3. Conjunctival challenge test (ophthalmic mucous membrane test)
  4. Cytotoxic food tests
  5. Rebuck skin window test
  6. Passive transfer or P-X (Prausnitz-Küstner) test

Clinical ecology services may be billed as allergy services, and should be denied as investigational. These services involve the diagnosis and treatment of environmental illness, which is defined as multiple complex allergies or toxicities which are alleged to cause symptomatic involvement of the gastrointestinal, musculoskeletal, respiratory, or central nervous system. These symptoms result from continued exposure to atmospheric contamination or exposure to common foods which may have been treated with pesticides and herbicides.

Examples of non-covered items considered to be used for environmental medicine/clinical ecology include but are not limited to:

  • Barrier cloth cover for mattresses
  • Cold packs to keep antigens frozen
  • Electric heater, mineral oil sealed, dimples
  • Half-mask respirator with organic vapor cartridges
  • Housecleaning services
  • Mold plates
  • Air filters, including portable air filter with air conditioner converter (HEPA)
  • RainbowTM vacuum cleaner
  • Syringes for anitgen injections
  • Water service

 

POLICY EXCEPTIONS

 Repeat testing  is not medically necessary unless there is clear documentation of rare and extraordinary circumstances as described in POLICY.

Hood Container Corp Union and Non-Union plans do not have a limit on allergy injections and testing.

 

POLICY GUIDELINES

 Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

 

POLICY HISTORY

 9/1992: Issued

2/1997: Revised: Limitation on number of tests; denial of repeat testing except in rare circumstances; moved two tests (nasal and conjunctival challenge) to Investigational list.

4/28/00 See clarification under POLICY.

5/23/2001: Code reference section updated; ICD-9 diagnosis codes 117.3, 496.7, and 708.3 deleted; non-covered codes table added

11/2001: Reviewed by MPAC; SDET or Rinkel Method changed to covered

2/11/2002: Investigational definition added

4/18/2002: Type of Service and Place of Service deleted

6/5/2002: Code Reference section updated

6/12/2002: ICD-9 diagnosis code 117.3, 692.73 and 708.3 added, CPT code 95078 moved to covered

11/3/2004: Code Reference section updated, CPT code 95078 description revised covered codes, ICD-9 diagnosis code range 477.0-477.9, 692.0-692.6, 692.72-692.74 listed separately covered codes, ICD-9 diagnosis 989.5 description revised covered codes, ICD-9 diagnosis code 692.84, E906.4, V15.01, V15.02, V15.03, V15.04, V15.05, V15.06, V15.07, V15.08, V15.09 added

09/12/2006:  Coding Updated.  ICD-9 2006 revisions added to policy

10/25/2006: Policy updated to include allergy testing limits are per day

12/21/2006: Code reference section updated per the 2007 CPT/HCPCS revisions

1/3/2007: Serial endpoint testing (SET) moved to investigational per BCBSA policy

1/4/2007: Code reference section updated; CPT 95027 moved to non-covered; describes SET

8/17/2007: Policy section partially re-written for clarity; no change in policy

8/22/2007: Code reference section reviewed. CPT 95015 moved to non-covered; describes SET

12/12/2007:Code reference section updated per the 2008 CPT/HCPCS revisions

12/24/2008: Code reference section updated per the 2009 CPT/HCPCS revisions

6/16/2009: Policy statement updated. Additional information regarding Serial Endpoint Testing (SET) added to the description section of the policy. Policy statement updated to include medically necessary indcations for Serial Endpoint Testing (SET). CPT code 95027 moved to covered table.

6/24/2009: CPT code 95015 moved to covered table

7/16/2009: Policy revisions approved by Medical Policy Advisory Committee (MPAC)

9/29/2009: Code reference section updated. Description revised for ICD-9 code V15.06. ICD-9 diagnosis code 995.2 deleted from covered table due to code was deleted as of 10-1-2006. CPT procedure code 95078 deleted from covered table due to code was deleted as of 12-31-2006.

03/22/2010: Code reference section updated. Code description revised for CPT code 82784. 

07/08/2010: Policy description unchanged. Policy statement regarding serial endpoint testing revised to change the term "systemic reaction" to "systemic allergic reaction." Intent of policy statement unchanged.

08/20/2011: Deleted information regarding leukocyte histamine release test (LHRT) and removed 86343 from the Code Reference section.

07/12/2012:  Added the following to the Policy Exceptions section:  Hood Container Corp Union and Non-Union plans do not have a limit on allergy injections and testing.

12/21/2012:  Added the following new 2013 CPT codes to the Code Reference section: 95017, 95018, 95076, and 95079.  

 

SOURCE(S)

 TEC Evaluations 1990: In Vitro Allergy Testing, p. 56

TEC Evaluations 1987: pp. 185 and 193

Blue Cross Blue Shield Association policy #2.01.23

Blue Cross Blue Shield Association policy #2.04.42

Hayes Medical Technology Directory

 

CODE REFERENCE

 This is not intended to be a comprehensive list of codes. Some covered procedure codes have multiple descriptions.

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document. 

Covered Codes

Code Number

Description

CPT

82785

Total Serum IgE Concentration

86003

Allergen specific IgE; quantitative; or semiquantitative, each allergen, (RAST, FAST, ELISA)

86005

Specific IgE; qualitative; multiallergen screen (MAST)

89190

Nasal smear for eosinophils

95004

Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, including test interpretation and report by a physician, specify number of tests (description revised 1-1-2008)

95010

Percutaneous tests (scratch, puncture, prick) sequential and incremental, with drugs, biologicals or venoms, immediate type reaction, including test interpretation and report by a physician, specify number of tests (revised description 1-1-2009) (Deleted 12-31-2012)

95015

Intracutaneous (intradermal) tests, sequential and incremental, with drug, biologicals, or venoms, immediate type reaction, including test interpretation and report by a physician, specify number of test (moved to non-covered 8-22-2007) (revised description 1-1-2009) (moved to covered table 6-24-09) (Deleted 12-31-2012)

95017Allergy testing, any combination of percutaneous (scratch, puncture, prick) and intracutaneous (intradermal), sequential and incremental, with venoms, immediate type reaction, including test interpretation and report, specify number of tests (New 01-01-2013)
95018Allergy testing, any combination of percutaneous (scratch, puncture, prick) and intracutaneous (intradermal), sequential and incremental, with drugs or biologicals, immediate type reaction, including test interpretation and report, specify number of tests (New 01-01-2013)

95024

Intracutaneous (intradermal) tests with allergenic extracts, immediate type reaction, including test interpretation and report by a physician, specify number of tests (description revised 1-1-2008)

95027

Intracutaneous (intradermal) tests, sequential and incremental, with allergenic extracts for airborne allergens, immediate type reaction, including test, interpretation and report by a physician, specify number of tests (revised description 1-1-2008) (moved to covered 6-16-2009)

95028

Direct Skin Test, Intracutaneous (with allergenic extracts, delayed; type reaction)

95044

Patch Test (Application Test)

95052

Photo Patch Test

95056

Photo tests

95070

Inhalation Bronchial Challenge Test (with histamine, methacholine, or similar compounds)

95071

Inhalation Bronchial Challenge Test (with antigens or gases), specify

95075

Ingestion Challenge Test (Deleted 12-31-2012)

95076Ingestion challenge test (sequential and incremental ingestion of test items, eg, food, drug or other substance); initial 120 minutes of testing (New 01-01-2013)
95079Ingestion challenge test (sequential and incremental ingestion of test items, eg, food, drug or other substance); each additional 60 minutes of testing (List separately in addition to code for primary procedure) (New 01-01-2013)

ICD-9 Procedure

 

 

ICD-9 Diagnosis

117.3

Aspergillosis (added 6-12-2002) 

279.03

Immune Deficiency Disease (IgE)

279.12

Wiskott-Aldrich syndrome

477.0, 477.1, 477.2, 477.8, 477.9

Allergic rhinitis code range

495.7

Ventilation pneumonitis (added 5-23-2001)

518.6

Aspergillosis (allergic bronchopulmonary) (added 5-23-2001)

692.0, 692.1, 692.2, 692.3, 692.4, 692.5, 692.6

Contact dermatitis and other eczema code range

692.72

Acute dermatitis due to solar radiation

692.73

Actinic reticuloid and actinic granuloma (added 6-12-2002)

692.74

Other chronic dermatitis due to solar radiation

692.81

Dermatitis due to contact with cosmetics

692.82

Photosensitization due to radiation other than sun (i.e., infrared rays, x-rays, light)

692.83

Dermatitis due to metals (i.e., jewelry)

692.84

Contact dermatitis and other eczema due to animal (cat, dog) dander (effective 10-4-2004) (added 11-3-2004)

692.89

Dermatitis due to other causes (i.e., dyes, furs, preservatives, etc.)

692.9

Contact dermatitis, unspecified cause

693.1

Dermatitis due to ingested food

693.8

Dermatitis due to other specified substance taken internally

693.9

Dermatitis due to unspecified substance taken internally

694.5

Pemphigoid

708.0

Allergic urticaria (added 5-23-2001)

708.3

Dermatographic urticaria (added 6-12-2002) 

989.5

Toxic effect of venom (i.e., spiders, ticks) (description revised 11-3-2004)

995.20

Unspecified adverse effect of unspecified drug, medicinal and biological substance. (new 10-1-2006)

995.21

Arthus phenomenon (new 10-1-2006)

995.22

Unspecified adverse effect of anesthesia (new 10-1-2006)

995.23

Unspecified adverse effect of insulin (new 10-1-2006)

995.27

Other drug allergy (new 10-1-2006)

995.29

Unspecified adverse effect of other drug, medicinal and biological substance. (new 10-1-2006)

995.3

Allergic reaction

E906.4

Bite of nonvenomous arthropod (added 11-3-2004)

V15.01

Personal history of allergy to peanuts (added 11-3-2004)

V15.02

Personal history of allergy to milk products (added 11-3-2004)

V15.03

Personal history of allergy to eggs (added 11-3-2004)

V15.04

Personal history of allergy to seafood (added 11-3-2004))

V15.05

Personal history of allergy to other foods (added 11-3-2004)

V15.06

Allergy to insects and arachnids (added 11-3-2004) (description revised 10-1-2009)

V15.07

Personal history of allergy to latex (added 11-3-2004)

V15.08

Personal history of allergy to radiographic dye (added 11-3-2004)

V15.09

Personal history of other allergy, other than to medicinal agents (added 11-3-2004)

V72.7

Encounter for diagnostic skin and sensitization tests

HCPCS

 

 

This is not an all-inclusive list of non-covered procedure codes.

The code(s) listed below and ANY code not listed in the previous section are considered non-covered for this procedure. 

Non-Covered Codes

Code Number

Description

CPT-4

82784

Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each (description revised 1-1-2010)

95060

Ophthalmic mucus membrane test (added 5-23-2001)

95065Direct nasal mucus membrane test (added 5-23-2001) 
95199 Unlisted allergy/clinical immunologic service or procedure [clinical ecology] (added 6-5-2002) 
ICD-9 Procedure
  
ICD-9 Diagnosis
  
HCPCS
  

 

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