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DESCRIPTIONIdiopathic environmental intolerance is typically characterized by recurrent, nonspecific symptoms that the patient or clinician believes are provoked by low levels of exposure to chemical, biologic or physical agents. Reported symptoms are wide-ranging, and there are not clearly established diagnostic criteria. Various tests e.g., nutritional assessment and treatment e.g., immunoglobulin therapy (IVIg), have been proposed.
Idiopathic environment intolerance has been labeled in a variety of ways over time. Clinical ecology, the original term, was replaced by the term multiple chemical sensitivity (MCS). Most recently, it has been replaced by idiopathic environmental intolerance which reflects the uncertain nature of the condition and its relationship to chemical exposure. The central focus of the condition is patient reporting of recurrent, nonspecific symptoms referable to multiple organ systems that the patient believes are provoked by exposure to low levels of chemical, biologic or physical agents. The most common environmental exposures include perfumes and scented products, pesticides, domestic and industrial solvents, new carpets, car exhaust, gasoline and diesel fumes, urban air pollution, cigarette smoke, plastics and formaldehyde. Certain foods, food additives, drugs, electromagnetic fields, and mercury in dental fillings have also been reported as triggering events. However symptoms do not bear any relationship to established toxic effects of the specific chemical and occur at concentrations far below those expected to elicit toxicity.
Reported symptoms are markedly variable, but generally involve either the central nervous system, respiratory and mucosal irritation, or gastrointestinal symptoms. Symptoms may include fatigue, difficulty in concentrating, depressed mood, memory loss, weakness, dizziness, headaches, heat intolerance and arthralgia. In contrast to the frequently debilitating symptomatology, no specific and consistent abnormalities are noted on laboratory or other diagnostic testing. Other primarily subjectively defined disorders have symptoms that overlap with idiopathic environmental intolerance including chronic fatigue syndrome, sick building syndrome, fibromyalgia, irritable bowel syndrome, and Gulf War syndrome. Intestinal dysbiosis is a diagnosis that could be considered within the category of idiopathic environmental intolerance. Refer to the Fecal Analysis in the Diagnosis of Intestinal Dysbiosis medical policy.
The variable nature of the reported symptoms and the lack of recognized pathologic abnormalities make it extremely difficult to establish objective diagnostic criteria for the condition, which further hinders research into both the causes and appropriate treatment. Various causes for idiopathic environmental intolerances have been proposed; these have prompted different diagnostic and treatment approaches. Some believe that the condition is an unrecognized form of allergy or immunologic hypersensitivity. Advocates of this etiology may recommend a large series of immunologic tests, including a variety of provocation-neutralization tests and a panel of immunologic tests, including immune function tests (eg, deregulation of the 2,5A RNase L antiviral pathway in peripheral mononuclear blood cells) and levels of lymphocyte subsets (i.e., natural killer cells, CD8 cells). Proposed therapies have included avoidance of exposure, either or both in the environment or in the diet. IVIg may be recommended for injection or sublingual drops of “neutralizing” chemical and food extracts. Others have proposed that exposure to toxic substances may have prompted the immunologic abnormality and, based on this theory, testing of levels of environmental chemicals in the blood, urine, or fat may be suggested. Detailed nutritional analyses have also been performed, including levels of trace minerals in the blood, urine or intracellular levels. Such elaborate nutritional assessments may also be performed in asymptomatic subjects. For example, Functional Intracellular Analysis (FIA™) is a series of laboratory tests offered by SpectraCell Labs that measure the intracellular levels of micronutrients, such as vitamins, minerals, and antioxidants in lymphocytes.
In some instances, symptoms may appear to coincide after exposure to a viral illness (particularly common in the related condition of chronic fatigue syndrome); supporters of this theory may recommend a wide variety of tests to detect antibodies or antigens of various viruses. Some have suggested that hypersentivity to Candida may present with a similar array of subjective complaints, and thus recommend testing for Candida in the stool or urine. Finally, it has been proposed that idiopathic environmental intolerance is a manifestation of a psychiatric disease or personality disorder based in part on results of psychologic/psychiatric interviews.
It should be noted that some environmentally causes illnesses can be well characterized by their clinical presentation and laboratory tests. For example, in certain instances “sick building” syndrome can be traced back to exposure of microorganisms related to air-handling symptoms. However, in contrast to idiopathic environmental intolerances, these patients experience a limited range of symptoms, and they occur in the affected building only.
No specific U.S. Food and Drug Administration (FDA) approval or clearance of a test for idiopathic environmental intolerance was found.
POLICYLaboratory tests designed to affirm the diagnosis of idiopathic environmental intolerance are considered investigational.
Nutritional assessments, including intracellular analysis of micronutrients, are considered investigational in both asymptomatic persons and patients with symptoms suggestive of idiopathic environmental intolerance.
Treatments for idiopathic environmental intolerance, including but not limited to IVIg, neutralizing therapy of chemical and food extracts, avoidance therapy, elimination diets, and oral nystatin (to treat Candida) are considered investigational.
POLICY GUIDELINESInvestigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY5/18/2006: Approved by Medical Policy Advisory Committee (MPAC)
1/8/2009: Policy reviewed, no changes
06/07/2010: Policy description updated regarding symptoms; added link to the Fecal Analysis in the Diagnosis of Intestinal Dysbiosis medical policy. For clarification and consistency purposes, "environmental illness" was changed to "environmental intolerance" throughout the policy. Intent of policy statements unchanged.
07/29/2011: Policy reviewed; no changes.
06/06/2012: Policy reviewed; no changes.
09/03/2013: Policy statement regarding treatments updated to state "including but not limited to" the treatments listed.
07/02/2014: Policy title changed from "Diagnosis and Management of Idiopathic Environmental Intolerance (i.e. Clinical Ecology)" to "Diagnosis and Management of Idiopathic Environmental Intolerance (i.e. Multiple Chemical Sensitivities)." Policy description updated. Policy statements unchanged.
04/26/2016: Policy Guidelines updated to revise investigational definition.
SOURCE(S)Blue Cross Blue Shield Association policy # 2.01.01
CODE REFERENCEAll codes billed are considered investigational and not eligible for coverage.