Allergy testing is performed to determine a patient's sensitivity to particular allergens and is based on the findings during a complete history and physical examination of the patient. Payment is made for medically necessary direct skin testing (percutaneous and intracutaneous) in or out of the hospital. Intracutaneous testing is considered to be a more sensitive but less specific testing method than percutaneous testing for the detection of IGE antibodies.

Payment for percutaneous (scratch, prick, puncture) tests (95004-95010) and intracutaneous (intradermal) tests (95015-95024, 95028) is limited to a total of 60 tests per patient per year (365 day period), regardless of the method of testing. Payment should not be made for allergy tests in excess of this limit except in extraordinary circumstances. In most instances, fewer than this established maximum is needed to appropriately evaluate the patient. A participating, preferred, or network, provider cannot bill the member for tests in excess of this limit.

Skin endpoint titration (SET) technique is used in conjunction with immuno-therapy to determine a starting point for a patient's sensitivity from an IgE standpoint for the allergen (antigen) in question. Generally, it takes 3 tests (dilutions) per allergen to determine the endpoint. Payment should be made on a per allergen basis under code 95027 and are not subject to the 60 test limitation specified in the preceding paragraph.

The following allergy testing methods are beyond the experimental/investigational stage but are not generally accepted by the medical community as clinically useful in diagnosing or treatment of allergies. Therefore, they are considered not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied test.

1. Cytotoxic food testing
2. Leukocyte histamine release (86343)
3. Provocative testing, e.g. Rinkel (95078)
4. Sublingual (antigens prepared for sublingual administration)

Refer to Medical Policy Bulletin L-3 for information on in vitro allergy testing.

Description

Allergic or hypersensitivity disorders may be manifested by generalized systemic reactions in any organ system of the body. The reactions may be acute, sub-acute or chronic, immediate or delayed, and may be caused by an endless variety of fur, venoms, foods, drugs, etc. The ideal management of the allergic patient is to identify the offending agent by various means of testing.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.