ModifiedAlliance HealthPolicy 1N-1

Allergy testing (skin and serologic)

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This policy defines medical necessity, coverage criteria, and covered methods for allergy testing (in vivo skin tests and in vitro specific IgE tests) for NC Medicaid beneficiaries and providers performing or ordering these tests.

Policy Summary

PayerAlliance Health

PolicyAllergy testing (skin and serologic)

Policy CodePolicy 1N-1

Change TypeReformatted criteriaunit limit updatesadded definitions

Effective Date

Last ReviewFeb 1, 2025

Next Review Date

Key ActionDocument medical/immunologic history, physical exam, exposure probability, and that symptoms are not controllable by empiric conservative therapy before ordering allergy testing.

SourceLink

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ModifiedAlliance HealthPolicy 1N-1

Allergy testing (skin and serologic)

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Policy Summary

PayerAlliance Health

PolicyAllergy testing (skin and serologic)

Policy CodePolicy 1N-1

Change TypeReformatted criteriaunit limit updatesadded definitions

Effective Date

Last ReviewFeb 1, 2025

Next Review Date

Key ActionDocument medical/immunologic history, physical exam, exposure probability, and that symptoms are not controllable by empiric conservative therapy before ordering allergy testing.

SourceLink

POLICY UPDATE CHANGES

Reformatted specific coverage criteria and clarified ordering and documentation steps for establishing exposure and uncontrolled symptoms.

Changed unit limitations for multiple CPT codes (86003, 86005, 95004, 95017, 95018, 95024, 95027, 95028, 95044, 95052, 95056, 95070, 95076, 95079).

Added definitions for Immunoglobulin antibody, In Vivo Testing and In Vitro Testing.

NCapplicable state

7required documentation items

7covered test types

10+investigational tests listed

Attachment Aunit limits updated

Coverage Criteria for Allergy Testing

Specific Criteria Covered (Pre-test and general medical necessity)

Medicaid shall cover Allergy Testing when the beneficiary meets the following specific criteria:

Pre-test requirements

History and exam: Completes a medical and immunologic history, along with a physical exam
Signs or diagnosis: Determines, upon completion of the history and physical exam, either: A) signs and symptoms are suggestive of an allergy OR B) a diagnosis indicates an allergy (e.g., asthma)1 of 2
Exposure probability: Establishes reasonable probability of exposure in the beneficiary's environment
Conservative therapy failed or uncontrolled: Documents in the health record that symptoms are not controllable by empiric conservative therapy
Tried and failed treatments: Documents in the health record all tried and failed allergy treatments
Select evidence-based test: Selects the appropriate allergy test with proven efficacy published in peer-reviewed literature
Order justification: Orders the allergy test based on findings from items 1–6 that document and appropriately support the antigen being used for testing

General medical necessity: Services must be individualized, specific, consistent with symptoms or confirmed diagnosis, safe to furnish, no equally effective and more conservative/less costly statewide alternative, and not primarily for convenience

From General Criteria Covered

Specific criteria covered by Medicaid — Covered when ALL of the following are met

Covered when ALL of the following are met

Medicaid coverage prerequisites: 1) Service provided by a physician or qualified non-physician practitioner after completion of a medical and immunologic history and physical exam; 2) On exam/history, either signs/symptoms are suggestive of an allergy OR a diagnosis indicates an allergy (e.g., asthma); 3) Establish reasonable probability of exposure in beneficiary's environment; 4) Document that symptoms are not controllable by empiric conservative therapy; 5) Document all tried and failed allergy treatments; 6) Select appropriate allergy test with proven efficacy published in peer-reviewed literature; 7) Order test based on findings that support the antigen being tested.

All conditions must be met before testing is covered.

Specific criteria for coverage (reformatted) — ordering and documentation requirements including failure of empiric therapy

Covered when documentation meets the policy's ordering and documentation requirements including failure of empiric therapy and reasonable probability of exposure:

Ordering and documentation requirements (summary): Provider documents that symptoms are not controllable by empiric conservative therapy; establishes reasonable probability of exposure in the beneficiary's environment; and orders tests based on findings that document and appropriately support testing.

Section 3.2.1 reformatted 02/01/2025 to add explicit requirement that symptoms be uncontrolled by empiric conservative therapy and to clarify ordering steps.

Medicaid: None Apply.

Coverage is excluded when any of the following apply: the beneficiary does not meet the eligibility requirements in Section 2.0; the beneficiary does not meet the criteria in Section 3.0; the procedure, product, or service duplicates another provider's procedure, product, or service; or the procedure, product, or service is experimental, investigational, or part of a clinical trial.

Attachment updates previously removed a listing of specific in vitro IgE tests and their criteria (historical change). The policy's revision log documents multiple attachment and template updates over time, including addition of definitions in Section 1.1 on 02/01/2025 and earlier Attachment A/section changes that affected how tests and code limits were presented.

The following tests are considered investigational and are not covered under this policy (examples listed in the policy): Leukocyte histamine release, Rebuck skin window, Prausnitz-Kustner test, Cytotoxic food testing (leukocytotoxic/Bryans test), Conjunctival challenge testing, Nasal challenge (provocative) testing, Kinesiology testing, Provocation‑neutralization testing, and Electrodermal testing. Investigational tests proposed for a beneficiary will be treated as not medically necessary.

Allergy testing will not meet coverage requirements if the medical record does not document that the beneficiary's symptoms are not controllable by empiric conservative therapy. The 02/01/2025 reformat of Section 3.2.1 added explicit language requiring documentation that symptoms remain uncontrolled by empiric conservative therapy as a condition of ordering and coverage.

Coding, Units, and Limitations

Coding references (ICD-10, CPT, Modifiers, Billing units)mixed

No codes listed

Referenced CPT codes with historical/unit limitation notesCPT

95004	CPT code referenced in Attachment A unit limitation history
95024	CPT code referenced in Attachment A unit limitation history
95027	CPT code referenced in Attachment A unit limitation history
95028	CPT code referenced in Attachment A unit limitation history
86003	CPT code referenced in Attachment A unit limitation history
95044	CPT code referenced in Attachment A unit limitation history
95070	CPT code referenced in Attachment A unit limitation history
95071	CPT code referenced in Attachment A unit limitation history
95076	CPT code referenced in Attachment A unit limitation history
95079	CPT code referenced in Attachment A unit limitation history

1–10 of 12

1/2

Code limits for allergy testingCPT

86003	Specific IgE testing — Testing Limitations = 30 units per 365 calendar days
86005	Specific IgE — Testing Limitations = 2 units per day up to 30 allergens per 365 calendar days
95004	Percutaneous skin test — Testing Limitations = 80 units per 365 calendar days
95017	Intradermal test — Testing Limitations = 27 units per date of service
95018	Intradermal test — Testing Limitations = 19 units per date of service
95024	Patch or similar testing — Testing Limitations = 30 units per 365 calendar days
95027	Allergen testing unit — Testing Limitations = 20 units per 365 calendar days
95028	Allergen testing unit — Testing Limitations = 20 units per 365 calendar days
95044	Allergen related test — Testing Limitations = 80 units per 365 calendar days
95052	Allergen test — Testing Limitations = 36 units per date of service

1–10 of 14

1/2

Unit limitations (historical examples)

95004 (historical)75 units per year (Attachment A change 02/01/2015)

95024 / 95027 / 95028 (historical)20 units per year (Attachment A change 02/01/2015)

86003 / 95044 (historical)36 units per year (Attachment A change 02/01/2015)

95070 / 95071 / 95076 (historical)Limited to 1 unit per date of service (Attachment A change 02/01/2015)

95079 (historical)Limited to 8 units per date of service (02/01/2015) then changed to 2 units per date of service (09/01/2015)

95017 / 95018 (historical)Limited to 30 units per date of service (02/01/2015); 95018 later changed to 19 units per date of service (09/01/2015)

Provider Actions, Documentation, and Billing Guidance

Prior Authorization

Claims and Prior Authorization Guidance

Claims and prior authorization: Providers must follow NCTracks guidance and Medicaid billing resources. Prior approval is not required for allergy testing; however, providers should reference the NCTracks Provider Claims and Billing Assistance Guide, Medicaid bulletins, fee schedules, and NC Medicaid clinical coverage policies for specific coverage, reimbursement, and claim-submission rules.

Prior approval is NOT required for Allergy Testing.
Providers must comply with NCTracks Provider Claims and Billing Assistance Guide, Medicaid bulletins, fee schedules, and NC Medicaid clinical coverage policies for claims and reimbursement.

Documentation Required

Required Documentation Before Testing

Required documentation before testing: A physician or qualified non-physician practitioner must complete and document a medical and immunologic history and a physical examination. The record must show that, based on the history and exam, either signs/symptoms are suggestive of an allergy or a diagnosis indicates an allergy (for example, asthma). The provider must also document a reasonable probability of exposure to the antigen in the beneficiary's environment.

Definitions

Allergy (IgE-mediated hypersensitivity)

DefinitionAn abnormally hypersensitive immune reaction mediated by immunoglobulin E (IgE) antibodies to specific allergens; reactions may be localized or systemic and can be acute, subacute, or chronic.

Common allergensIncludes pollen, molds, foods, drugs, insect stings, animal dander, and dust mites.

Testing purposeTesting detects sensitization by measuring allergen-specific IgE via in vivo (skin) or in vitro (serologic) methods, but sensitization alone does not confirm clinical allergy.

Immunoglobulin E (IgE) Antibody

DefinitionImmunoglobulin E (IgE) antibody is a type of protein in the body that plays a role in allergic reactions by producing symptoms commonly in the nose, throat, lungs, and skin.

Role

Background

Allergy refers to IgE-mediated hypersensitivity reactions to environmental or ingested allergens (for example, pollen, molds, foods, drugs, insect stings, animal dander, and dust mites). Testing for allergy includes in vivo skin testing and in vitro specific IgE serologic testing to detect sensitization, but documentation must show a clinical history and findings that correlate with testing because sensitization alone does not confirm clinical allergy.

Policy Summary

PayerAlliance Health

PolicyAllergy testing (skin and serologic)

Policy CodePolicy 1N-1

Change TypeReformatted criteriaunit limit updatesadded definitions

Effective Date

Last ReviewFeb 1, 2025

Next Review Date

Key ActionDocument medical/immunologic history, physical exam, exposure probability, and that symptoms are not controllable by empiric conservative therapy before ordering allergy testing.

SourceLink

On This Page

Units per time period (Attachment A, Section C)

8600330 units per 365 calendar days

860052 units per day, up to 30 allergens per 365 calendar days

9500480 units per 365 calendar days

9501727 units per date of service

9501819 units per date of service

95027 / 9502820 units per 365 calendar days

950792 units per date of service

Complete medical and immunologic history and physical exam documented in the health record.
Documentation that signs/symptoms are suggestive of an allergy or a diagnosis indicating allergy (e.g., asthma).
Establish and document reasonable probability of exposure in the beneficiary's environment.

Documentation Required

Conservative Therapy and Symptom Documentation

Documentation of symptoms and conservative therapy: The health record must document that the beneficiary's symptoms are not controllable by empiric conservative therapy and must list all allergy treatments that were tried and failed prior to ordering testing. The allergy test ordered must be selected based on findings that appropriately support testing for the specific antigen.

Document that symptoms are not controllable by empiric conservative therapy.
Document all tried and failed allergy treatments in the health record.
Order the allergy test only when findings from the history, exam, exposure assessment, and prior treatment documentation support testing for the specific antigen.

Billing Rule

Billing Units

Billing units: Providers must report the appropriate CPT/HCPCS code which determines the billing unit. Each specific allergen or antigen tested must be billed as one unit, even if multiple injections, pricks, or dilutions are performed for that antigen on the same day. For CPT 95027, one unit equals one allergen tested (not the number of dilutions). Follow NCTracks and fee schedule unit limits where applicable.

For CPT 86003, bill one unit per specific allergen tested (one test = one unit).
Each antigen tested must be billed as one unit, regardless of number of injections/scratches/pricks used the same day.
For CPT 95027, one unit = one allergen tested (do not bill per dilution).
Adhere to NCTracks and Medicaid fee schedule unit limits for each CPT code.

Note

EPSDT and Prior Approval

EPSDT and beneficiaries under 21: The requirement for prior approval remains in effect for services that require prior approval even when the beneficiary is under 21. Providers should consult EPSDT resources and NCTracks guidance for additional EPSDT-related requirements.

Being under 21 does NOT waive prior approval requirements for services that otherwise require prior approval.
Refer to NCTracks and EPSDT guidance for further information.

Mediates hypersensitivity responses when bound to specific allergens, leading to clinical signs and symptoms.

Use in testingMeasured in serologic (in vitro) tests and referenced in interpretation of skin (in vivo) testing results.

Serological testing (In vitro)

DefinitionSerological testing (in vitro) are blood tests performed outside of a living organism (e.g., in a laboratory) to detect allergen-specific antibodies such as IgE.

PurposeDetermines whether an individual has been exposed to or sensitized to a particular allergen by detecting antibodies in serum.

LimitationsDetects sensitization but does not by itself establish clinical allergy; results must be interpreted with history and exam.

Testing (In vivo / Skin testing)

DefinitionTesting (In vivo / Skin testing) refers to tests performed within a living organism such as skin prick (percutaneous) or intradermal testing to assess reactivity to specific allergens.

MechanismRelies on the skin's reactivity and sensitivity to controlled exposure to allergens applied percutaneously or intradermally.

InterpretationResults indicate sensitization and must be correlated with clinical history because positive tests alone do not confirm clinical allergy.

In Vivo Testing

DefinitionIn Vivo Testing: procedures conducted within a living organism (e.g., skin prick or intradermal tests) to evaluate allergic reactivity to specific allergens.

ExamplesPercutaneous (scratch/prick) testing and intradermal testing.

Billing noteEach specific allergen tested is reported as one billing unit; multiple applications of the same antigen are still one unit per antigen (see Billing Units).

In Vitro Testing

DefinitionIn Vitro Testing: laboratory serologic tests performed outside the body (blood tests) that measure allergen-specific IgE antibodies.

ExamplesSpecific IgE assays (e.g., CPT 86003, 86005) used to detect sensitization to individual or multiple allergens.

InterpretationDetects sensitization but must be correlated with clinical findings; used when skin testing is contraindicated or impractical.

Immunoglobulin antibody

DefinitionImmunoglobulin antibody: refers to antibody proteins such as IgE that mediate allergic sensitization and are measured by serologic testing.

Clinical relevancePresence of allergen-specific immunoglobulin indicates sensitization but not necessarily clinical allergy; correlate with history/exam.

Role in policyDefined term added to Section 1.1 to clarify terminology used in the policy (02/01/2025 revision).

Definitions added (02/01/2025)

Change summaryDefinitions for Immunoglobulin antibody, In Vivo Testing, and In Vitro Testing were added to Section 1.1 on 02/01/2025 to clarify testing modalities and terminology.

Effective sectionSection 1.1 (Definitions) was revised 02/01/2025 to include these terms.

PurposeClarifies terminology used elsewhere in the policy and aligns definitions with the coverage and coding sections.