Selection criteria required for testing

Selection criteria required for allergy testing. Testing should only be performed when all three core selection criteria are met to ensure clinical relevance and evidence-based use of diagnostics.

• Symptoms are not adequately controlled by empiric conservative therapy (uncontrolled symptoms).
• Testing findings must correlate to the member's history, risk of exposure and physical findings.
• Test technique and allergens tested must have proven efficacy demonstrated through peer-reviewed scientific studies (evidence-based diagnostic testing).

Documentation requirements for testing and immunotherapy

Document specific clinical indications and required elements in the medical record for specialty tests and procedures. Maintain clear, contemporaneous documentation to support medical necessity, timing, and services billed.

• Document indication for alpha-gal testing: history of delayed urticaria/angioedema/anaphylaxis or gastrointestinal symptoms with presyncope/syncope within ~3–6 hours after ingesting mammalian meat.
• Confirm IgE-mediated allergy before initiating immunotherapy: positive skin test and/or serologic evidence to a relevant, potent extract correlated with clinical history.
• Medical record documentation required: symptom history, prior conservative therapies and response, exposure history, test rationale, signed consent when applicable, and monitoring/administration location.
• Separate E/M documentation required when billing evaluation and management on the same day as immunotherapy: ensure distinct, reportable E/M content/time is documented independent of immunotherapy visit.
• Include specifics for venom immunotherapy: number of venoms to be treated, vials required, and schedule justification in the record.

Billing rules and limits

Billing and utilization limits and rules that affect ordering and reimbursement of allergy tests and related items. Follow code-specific limits and restrictions.

• Limit counts for in vitro specific IgE testing: up to 40 inhalant tests (e.g., 86003) and up to 12 food/other tests (e.g., 86005/86008) for an initial allergy screen; additional tests only if initial screen positive.
• Percutaneous tests (skin prick) are not medically necessary when performed after initiation of immunotherapy for routine monitoring (CPT 95004, 95017, 95018). Repeat percutaneous testing is allowed only if new sensitivities are suspected during/after immunotherapy or if the patient failed to respond to immunotherapy.
• Avoid billing simultaneous blood and skin testing for the same allergens (see denial risk) — performance of both percutaneous allergy tests and IgE RAST tests (blood) for the same allergens is considered not medically necessary.
• Epinephrine auto-injector prescribing: epinephrine kits (e.g., EpiPen) are medically necessary for those with prior life-threatening reactions or severe asthma or during immunotherapy as clinically indicated — ensure documentation if there are billing implications.
• Depot intramuscular steroid injections for allergic rhinitis: claims may be denied as not medically necessary for routine AR management (risk of depot steroid denial).

Denial risk highlights

Denial risks and common reasons for noncoverage. Ensure testing and procedures are supported by clinical history and evidence-based indications to avoid denials.

• Not medically necessary: simultaneous blood (in vitro IgE) and skin testing for the same allergens (e.g., CPT 95004 and 86003) — duplication without justification may be denied.
• Use of experimental or unproven tests may be denied — examples include ALCAT and other tests listed in the experimental and investigational section (refer to policy experimental list). Novel or proprietary assays lacking peer-reviewed validation require strong evidence-based justification.
• Claims for depot intramuscular steroid injections for allergic rhinitis may be denied as not medically necessary; document alternatives tried and rationale if used.

Prior authorization and administration requirements for immunotherapy and novel therapies

Certain immunotherapy administrations and novel therapies require facility capability, trained personnel, and/or prior authorization. Novel or non-standard immunotherapies require explicit prior authorization and evidence-based justification.

• Facility and personnel requirements for immunotherapy: must be administered in a medical facility with trained staff and equipment available to manage anaphylaxis (e.g., immediate access to epinephrine, oxygen, resuscitation equipment).
• Administration and monitoring requirements: observe patients for an appropriate period post-injection per standard practice and document monitoring and any adverse events.
• Prior authorization required for novel or nonstandard therapies: intradermal immunotherapy, oral immunotherapy (OIT), sublingual immunotherapy (SLIT) initiation/maintenance in non-standard situations, and intranasal immunotherapy — these require evidence-based justification and prior authorization.
• Considerations for SLIT initiation and monitoring: follow guideline-endorsed dosing and monitoring recommendations; document patient selection, counseling on adverse events, and plan for management of systemic reactions.

Documentation for BAT and specialized in‑vitro tests

Specialized in‑vitro tests and basophil activation testing (BAT) have operational and interpretation requirements. Limited standardization and pre-analytic handling can affect validity; document handling and interpretive context.

• BAT and specialized in‑vitro assays require timely specimen handling and validated laboratory procedures; operational requirement example: whole blood samples for BAT may need processing within 24 hours per laboratory instructions.
• Limited standardization: emphasize that many specialized tests lack widespread standardization and should be used only when they will change management; document why conventional testing or oral food challenge (OFC) is not appropriate.
• Guidance on interpreting Chronic Urticaria Index and similar assays: include clinical correlation and acknowledge limitations in prognostication; document how results will impact clinical decision-making.
• Avoid routine specific IgE testing for FPIES; use OFC as the gold standard for food allergy diagnosis when appropriate, and document rationale if specialized testing is used.