Allergy Testing and Allergy Immunotherapy

Related Medicare Advantage Policy Guidelines:

 Antigens Prepared for Sublingual Administration (NCD 110.9)

 Challenge Ingestion Food Testing (NCD 110.12)

 Cytotoxic Food Tests (NCD 110.13)

 Food Allergy Testing and Treatment (NCD 110.11)

 Intravenous Histamine Therapy (NCD 30.6)

This information is being distributed to you for personal reference. The information belongs to UnitedHealthcare and unauthorized copying, use, and distribution are prohibited. This information is intended to serve only as a general reference resource and is not intended to address every aspect of a clinical situation. 

Physicians and patients should not rely on this information in making health care decisions. Physicians and patients must exercise their independent clinical discretion and judgment in determining care. Each benefit plan contains its own specific provisions for coverage, limitations, and exclusions as stated in the Member’s Evidence of Coverage (EOC)/Summary of Benefits (SB). 

If there is a discrepancy between this policy and the member’s EOC/SB, the member’s EOC/SB provision will govern. The information contained in this document is believed to be current as of the date noted.

The benefit information in this Coverage Summary is based on existing national coverage policy, however, Local Coverage

Determinations (LCDs) may exist and compliance with these policies is required where applicable. 

COVERAGE

Coverage Statement: Allergy testing and allergy immunotherapy (allergy therapy) are covered when Medicare coverage criteria are met.

Guidelines/Notes:

1. Allergy testing that may be covered include, but are not limited to:

a. Complete blood count (CBC) with differential (e.g., eosinophil count, IgE level, smear of a nasal secretions)

b. Chest X  -ray, when respiratory symptoms are present

c. Skin testing 

d. Total gamma globulins

e. Sputum exam 

f. Paranasal sinus X  -ray

g. Challenge ingestion - food testing

h. Radioallergosorbent Test (RAST) (CPT code 86003)

 Medicare does not have a National Coverage Determination (NCD) for RAST.

 Local Coverage Determinations (LCDs) which address IGE in Vitro Tests (e.g., RAST) exist and compliance with these LCDs is required where applicable. For state-specific LCDs, refer to the LCD Availability Grid (Attachment A).

 For states with no LCDs, refer to the MCG™ Care Guidelines, 20th edition, 2016, Quantitative Allergen-Specific IgE Antibody Assays ACG: A-0149 (AC) for coverage guidelines. 

(IMPORTANT NOTE: After searching the Medicare Coverage Database, if no state LCD or Local Article is found, then use the above referenced policy.)

 Committee approval date: September 20, 2016

2. Allergen immunotherapy to treat allergies is covered when:

a. Patient is examined by a physician

b. The physician who examines the patient, prepares the antigens and develops a plan of care and dosage regimen

Note: Physician should instruct member on self-administration if member is capable of doing the injections. If a member lives too far from the allergist (rural area) the allergist may prepare the antigens and send the reasonable supply to another physician or qualified healthcare professional for administration.

3. Reasonable Supply of Antigen Payment may be made for a reasonable supply of antigens that have been prepared for a particular patient if: 

(1) the antigens are prepared by a physician who is a doctor of medicine or osteopathy, and 

(2) the physician who prepared the antigens has examined the patient and has determined a plan of treatment and a dosage regimen.

Antigens must be administered in accordance with the plan of treatment and by a doctor of medicine or osteopathy or by a properly instructed person (who could be the patient) under the supervision of the doctor. 

The associations of allergists that CMS consulted advised that a reasonable supply of antigens is considered to be not more than a 12-month supply of antigens that has been prepared for a particular patient at any one time. 

The purpose of the reasonable supply limitation is to assure that the antigens retain their potency and effectiveness over the period in which they are to be administered to the patient. 

The following are examples of tests/services that are not covered but are not limited to:

a. Sublingual antigen; see the NCD for Antigens for Sublingual Administration (110.9) (Accessed December 17, 2015)

b. Intravenous histamine administration; see the NCD for Intravenous Histamines (30.6) (Accessed December 17, 2015)

c. Routine radioallergosorbent test (RAST) (see #1.h above)

d. Cytotoxicity testing/Bryan’s test; see the NCD for Cytotoxic Food Test (110.13) (Accessed December 17, 2015)

e. Urine autoinjection

f. Skin titration/Rinkel method

g. Provocative and neutralizing testing (subcutaneous) for food allergies; see the NCD for Food Allergy Testing and Treatment (110.11) (Accessed December 17, 2015)

h. Sublingual provocative test; see the NCD for Food Allergy Testing and Treatment (110.11) (Accessed December 17, 2015)

i. Serum allergy/histamine release tests 

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