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 80 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 80 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. Effective January 26, 2009, a participating, preferred, or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records.

1. Cytotoxic food testing
2. Leukocyte histamine release (86343)
3. Provocative testing, e.g. Rinkel
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.

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits or a contract. Benefits are determined by the Federal Employee Program.