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DESCRIPTIONAllergic 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:
8. Serial Endpoint Testing (SET)
POLICYThe following allergy tests are considered medically necessary in the diagnosis of the allergic patient:
Repeat skin testing with multiple antigens is not medically necessary unless there is clear documentation of rare and extraordinary circumstances such as:
The following allergy tests are considered investigational, and not covered:
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:
POLICY EXCEPTIONSRepeat 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 GUIDELINESInvestigative 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 HISTORY9/1992: 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 REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
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.