ALLERGY TESTING / IMMUNOTHERAPY

MEDICAL POLICY No. 91037-R7

I. POLICY/CRITERIA

A. The following allergy tests are covered benefits:

1. IgE Specific Antibody (e.g., RAST, micro-Elisa, immunocap) if clinically indicated for history of severe urticaria, hives, or severe allergy, when skin testing is inappropriate.

2. Skin tests (scratch, intradermal, pricks)

3. Patch application tests

4. Drug Provocation testing

5. Skin Endpoint Titration (SET). Skin endpoint titration is effective for quantifying patient sensitivity and for providing a safe starting dose for immunotherapy. SET has not been shown to be an effective guide to a final therapeutic dose.

B. The following services have not been proven to be effective in diagnosingand/or treating allergies, and are not covered benefits:

1. Cytotoxicity testing (Bryan's test)

2. Urine autoinjection (autogenous urine immunization)

3. Provocation testing and neutralization therapy for food allergy (intracutaneous, subcutaneous or sublingually). Also called Intracutaneous Progressive Dilution Food Test (IPDFT).

4. Antigen leukocyte cellular antibody test (ALCAT) for all indications including but not limited to testing for food allergies or intolerance (chemical sensitivities) and as a tool to establish elimination diets.

5. Electrodermal testing or electro-acupuncture*

6. Applied kinesiology or muscle strength testing of allergies

7. Reaginic pulse testing or pulse testing for allergies

8. Total serum immunoglobulin G (IgG), immunoglobulin A (IgA) and immunoglobulin M (IgM)

9. Testing of specific IgG antibody (e.g., by RAST or ELISA testing)

10. Lymphocyte subset counts

11. Lymphocyte function assay

12. Lymphocyte transformation test (LTT), also known as lymphocyte proliferation test and metal ion testing for metal-induced hypersensitivity response. 

13. Cytokine, cytokine receptor assay and Th1/Th2 cytokine ratio

14. Natural Killer (NK) cell assay or activity

15. Food immune complex assay (FICA)

16. Leukocyte histamine release testing

17. Body chemical analysis

18. Sublingual immunotherapy (SLIT) as an alternative way to treat allergies without injections. SLIT is not FDA approved in the United States

*Note: Acupuncture may be covered with a rider for some commercial plans.

IV. DESCRIPTION

Allergy testing, evaluations, and immunotherapy are eligible for coverage according to the schedule of covered services in plan documents. Testing or treatment methods not considered as standard medical procedures are not eligible for coverage.

V. CODING INFORMATION

ICD-10 Codes that may support medical necessity:

D69.0 Allergic purpura

H10.401 – H10.409 Unspecified chronic conjunctivitis

H10.421 – H10.429 Simple chronic conjunctivitis

H10.44 Vernal conjunctivitis

H16.261 – H16.269 Vernal keratoconjunctivitis, with limbar and corneal

H10.411 – H10.419 Chronic giant papillary conjunctivitis

H10.45 Other chronic allergic conjunctivitis

H10.9 Unspecified conjunctivitis

J30.0 – J30.9 Vasomotor and allergic rhinitis

J31.0 – J31.2 Chronic rhinitis, nasopharyngitis and pharyngitis

J32.0 – J32.9 Chronic sinusitis

J33.0 – J33.9 Nasal polyp

J45.20 – J45.998 Asthma

K52.2 Allergic and dietetic gastroenteritis and colitis

K52.89 Other specified noninfective gastroenteritis and colitis

K52.9 Noninfective gastroenteritis and colitis, unspecified

L20.0 – L20.9 Atopic dermatitis

L22 Diaper dermatitis

L23.0 – L23.9 Allergic contact dermatitis

L24.0 – L24.9 Irritant contact dermatitis

L25.0 – L25.9 Unspecified contact dermatitis

L27.0 – L27.9 Dermatitis due to substances taken internally

L29.8 Other pruritus

L29.9 Pruritus, unspecified

L30.0 – L30.9 Other and unspecified dermatitis

L50.0 Allergic urticaria

L50.1 Idiopathic urticaria

L50.6 Contact urticaria

L50.8 Other urticaria

L50.9 Urticaria, unspecified

L56.4 Polymorphous light eruption

T50.905A-T50.905S Adverse effect of unspecified drugs, medicaments and biological substances

T50.995A-T50.905S Adverse effect of other drugs, medicaments and biological substances

T78.00xA-T78.1xxS Anaphylactic reaction due to food

T78.40xA-T78.49xS Other and unspecified allergy

Z01.82 Encounter for allergy testing

Z91.010 – Z91.09 Allergy status, other than to drugs and biological substances

CPT/HCPCS Codes

Not covered for Priority Health Medicaid

Testing: (Laboratory tests are subject to laboratory benefits)

82785 Gammaglobulin; IgE

86001 Allergen specific IgG quantitative or semiquantitative, each allergen

86003 Allergen specific IgE; quantitative or semiquantitative, each allergen

86005 Allergen specific IgE; qualitative, multiallergen screen (dipstick, paddle or disk)

86021 Antibody identification; leukocyte antibodies

95004 Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, including test interpretation and report by a physician, specify number of tests.

95012 Nitric oxide expired gas determination

95017 Allergy testing, any combination of percutaneous (scratch, puncture, prick) and intracutaneous (intradermal), sequential and incremental, with venoms, immediate type reaction, including test interpretation and report, specify number of tests

95018 Allergy testing, any combination of percutaneous (scratch, puncture, prick) and intracutaneous (intradermal), sequential and incremental, with drugs or biologicals, immediate type reaction, including test interpretation and report, specify number of tests

95024 Intracutaneous (intradermal) tests with allergenic extracts, immediate type reaction, including test interpretation and report by a physician, specify number of tests.

95027 Intracutaneous (intradermal) tests, sequential and incremental, with allergenic extracts for airborne allergens, immediate type reaction, including test interpretation and report by a physician, specify number of tests.

95028 Intracutaneous (intradermal) tests with allergenic extracts, delayed type reaction, including reading, specify number of tests.

95044 Patch or application test(s), specify number of tests.

95052 Photo patch test(s), specify number of tests.

95056 Photo tests

95060 Ophthalmic mucous membrane tests

95065 Direct nasal mucous membrane test

95070 Inhalation bronchial challenge testing (not including necessary pulmonary function tests); with histamine, methacholine, or similar compounds.

95071 Inhalation bronchial challenge testing (not including necessary pulmonary function tests); with antigens or gases, specify number of tests.

95076 Ingestion challenge test (sequential and incremental ingestion of test items, eg, food, drug or other substance); initial 120 minutes of testing

95079 Ingestion challenge test (sequential and incremental ingestion of test items, eg, food, drug or other substance); each additional 60 minutes of testing (List separately in addition to code for primary procedure) 

Immunotherapy

95115 Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection 

95117 Professional services for allergen immunotherapy not including provision of allergenic extracts; two or more injections

95120 Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; single injection

95125 Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; two or more injections

95130 Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; single stinging insect venom

95131 Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; two stinging insect venoms

95132 Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; three stinging insect venoms

95133 Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; four stinging insect venoms

95134 Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; five stinging insect venoms

95144 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy, single dose vial(s) (specify number of vials)

95145 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); single stinging insect venom

95146 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); two single stinging insect venoms

95147 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); three single stinging insect venoms

95148 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); four single stinging insect venoms 

95149 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); five single stinging insect venoms

95165 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses)

95170 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; whole body extract of biting insect or other arthropod (specify number of doses)

95180 Rapid desensitization procedure, each hour (eg, insulin, penicillin, equine serum)

95199 Unlisted allergy/clinical immunologic service or procedure (Explanatory notes must accompany claims billed with unlisted codes.)

Not Covered for allergy testing:

83516 Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method

83518 Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, single step method (eg, reagent strip)

83519 Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, by radioimmunoassay (eg, RIA)

83520 Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified

86160 Complement; antigen, each component

86161 Complement; functional activity, each component

86162 Complement; total hemolytic (CH50)

86332 Immune complex assay

88342 Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure

88344 Immunohistochemistry or immunocytochemistry, per specimen; each multiplex antibody stain procedure

88346 Immunofluorescent study, each antibody; direct method

86352 Cellular function assay involving stimulation (eg, mitogen or antigen) and detection of biomarker (eg, ATP)

88184 Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; first marker

88185 Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; each additional marker (List separately in addition to code for first marker)

86343 Leukocyte histamine release test (LHR)

86353 Lymphocyte transformation, mitogen (phytomitogen) or antigen induced blastogenesis

95199 Unlisted allergy/clinical immunologic service or procedure (Explanatory notes must accompany claim) Code not covered if billed for service listed as “Not Covered in this policy.

86356 Mononuclear cell antigen, quantitative (eg, flow cytometry), not otherwise specified, each antigen