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.

The number of percutaneous tests (95004-95010) and intracutaneous (intradermal) tests (95015-95024, 95028) required for evaluation may vary widely from patient to patient.  The number of tests is dependent upon the patient's history, physical findings and provider clinical judgment and may require up to 70 percutaneous tests and 40 intracutaneous tests per patient per year (365 day period).  Payment should not be made for allergy skin 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.  Services exceeding this limitation are considered not medically necessary.

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 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. 

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

Services that do not meet the medical necessity guidelines on this policy are considered "not medically necessary."  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.

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.

Joint Council of Allergy, Asthma and Immunology, Practice Parameters for Allergy Diagnostic Test. Ann Allergy Asthma Immunol. 1995; 75:543-625.

Beyer K, Teuber SS. Food Allergy Diagnostics: Scientific and Unproven Procedures. Curr Opin Allergy Clin Immunol. 2005; 5(3):261-266.

Chapman JA, Bernstein IL, Lee RE, et al. Food Allergy: A Practice Parameter: Ann Allergy Asthma Immunol. 2006; 96:S1-S68.

American Academy of Allergy, Asthma and Immunology (AAAAI). Workgroup Report: Allergy Diagnosis in Clinical Practice. Nov 2006. www.aaai.org/medical/resources/academ_statements/.

Calabria CW, Hagan L. The Role of Intradermal Skin Testing in Inhalant Allergy. Ann Allergy Asthma Immunol. 2008; 101(4):337-347.

The American Academy of Allergy, Asthma and Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI) Joint Task Force.  Allergy Diagnostic Testing: An Updated Practice Parameter.  Annals of Allergy Asthma and Immunol. 2008; 100:S1-S148.