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CurrentAmbetter NevadaPolicy CP.MP.100

Allergy Testing and Therapy (Clinical Policy)

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Medical necessity, limitations, and coverage criteria for diagnostic allergy testing and allergen immunotherapy (skin, in vitro, patch, challenge testing and immunotherapy) for Ambetter Nevada members.

Policy Summary

PayerAmbetter Nevada

PolicyAllergy Testing and Therapy (Clinical Policy)

Policy CodePolicy CP.MP.100

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument clinical indications, testing results, and treatment rationale in the medical record when requesting coverage or prior authorization for allergy testing or immunotherapy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

14-28wksBuild-up period

12-24mAssess benefit

CPT 95004-95079,86003-86008Example codes

3-5yRe-eval interval

Multiple CPTCode lists

Coverage Criteria — Tests and Immunotherapy

Allergy testing - medical necessity

Covered when ALL of the following are met

Allergy testing medical necessity: Testing is part of a complete diagnostic evaluation by a licensed practitioner with appropriate history and physical and antigens reasonably possible for exposure; the number of tests performed must be judicious and related to the history, physical findings, and clinical judgment specific to each individual.

Preferred and acceptable test modalities include percutaneous testing (CPT 95004, 95017, 95018) as the test of choice for suspected IgE‑mediated allergy; intracutaneous/intradermal testing (CPT 95024, 95027, 95028) when percutaneous tests are negative or increased sensitivity is needed; in vitro specific IgE testing (CPT 86003, 86005, 86008) when skin testing is contraindicated or unreliable; patch testing (CPT 95044), photo patch (CPT 95052) or photo testing (CPT 95056) per criteria; and ingestion (oral) challenge testing (CPT 95076, 95079) when appropriate.

Allergen immunotherapy - facility administration

Covered when ALL of the following are met

Immunotherapy facility administration criteria:

Policy Summary

PayerAmbetter Nevada

PolicyAllergy Testing and Therapy (Clinical Policy)

Policy CodePolicy CP.MP.100

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument clinical indications, testing results, and treatment rationale in the medical record when requesting coverage or prior authorization for allergy testing or immunotherapy.

SourceLink

On This Page

Medically Necessary Procedures with Diagnosis

Procedure codes are considered medically necessary when diagnosis code requirements are met per the ICD-10 tables and proper preparation/administration standards are followed.

Main coverage conditions: Claims for listed CPT procedure codes in CPT Code Table 1 (eg, 86003, 86005, 86008, 86160-86162, 95004-95028, 95044, 95052, 95056, 95076-95079, 95115, 95117, 95144, etc.) will be considered medically necessary when a supporting ICD-10 diagnosis from the corresponding ICD-10 code tables is present AND immunotherapy preparation, storage, and administration are performed by trained personnel following documented standard operating procedures and aseptic technique standards.

See CPT Code Table 1 and ICD-10 Code Tables for the specific CPT–ICD-10 mappings and required diagnoses; professional supervision and documentation requirements (medical/immunologic history, face‑to‑face exam, test methodology and measured results, interpretation, and how results affect plan of care) must be met.

The policy lists specific antigens and a broad set of tests and procedures that are not medically necessary. Examples of antigens explicitly listed include newsprint, tobacco smoke, dandelion, orris root, phenol, alcohol, sugar, yeast, grain mill dust, soybean dust (unless documented exposure), wool (unless continuous exposure), and additional environmental items such as marigold, honeysuckle, fiberglass, green tea, chalk, cornstarch, cotton, formaldehyde, and smog.

A large number of diagnostic tests and investigational procedures are also considered not medically necessary, including but not limited to ALCAT automated food allergy testing; applied kinesiology/NAET; anti-Fc epsilon receptor and anti-IgE receptor antibody testing; micronutrient panels; candidiasis testing; chemical analysis of body tissues; chronic urticarial index; Clifford materials reactivity; complement antigen testing; C-reactive protein; cytokine assays; cytotoxic food testing (Bryans Test, ACT); electrodermal testing; immune complex assays; in vitro IgG testing; leukocyte/basophil histamine release tests; live cell analysis; lymphocyte function assays; mediator release tests; provocation/neutralization testing and neutralization therapy; and VeriMAP Peanut Diagnostic™.

Certain services related to immunotherapy are also considered not medically necessary, including desensitization with whole-body extracts for hymenoptera (except venom extracts), food allergenic extract immunotherapy, intracutaneous desensitization (Rinkel Injection Therapy), repository emulsion therapy, non‑FDA approved sublingual immunotherapy, home administration of allergy immunotherapy, intradermal testing for food allergies, and rush immunotherapy for inhalant allergens.

Coding — CPT and ICD-10 Tables

Covered CPT Codes - Percutaneous testingCPTCovered

95004	Percutaneous testing (scratch, puncture, prick)
95017	Percutaneous testing additional
95018	Percutaneous testing additional

Covered CPT Codes - Intracutaneous/intradermalCPTCovered

95024	Intracutaneous (intradermal) test
95027	Intracutaneous/intradermal testing / skin end-point titration
95028	Intracutaneous testing additional

Covered CPT Codes - In vitro specific IgE testingCPTCovered

86003	Allergen specific IgE; per allergen
86005	Allergen specific IgE; multiple
86008	Allergen specific IgE; other

Covered CPT Codes - Patch testingCPTCovered

95044

Patch or application testing

Covered CPT Codes - Photo patch testingCPTCovered

95052

Photo patch test

Covered CPT Codes - Photo testingCPTCovered

95056

Photo testing

Covered CPT Codes - Oral/ingestion challengeCPTCovered

95076	Ingestion (oral) challenge testing
95079	Oral food challenge additional

Covered CPT CodesCPTCovered

86003	Allergen specific IgE; quantitative or semiquantitative, crude allergen extract, each.
86005	Allergen specific IgE; qualitative, multiallergen screen (eg, disk, sponge, card).
86008	Allergen specific IgE; quantitative or semiquantitative, recombinant or purified component, each.
86160	Complement; antigen, each component.
86161	Complement; functional activity, each component.
86162	Complement; total hemolytic (CH50).
95004	Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of tests.
95017	Allergy testing, any combination of percutaneous and intracutaneous, with venoms, immediate type reaction, including test interpretation and report, specify number of tests.
95018	Allergy testing, any combination of percutaneous and intracutaneous, 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, specify number of tests.

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Procedure codes considered not medically necessaryCPT | HCPCSNot Covered

86001	Allergen specific IgG quantitative or semiquantitative, each allergen.
86332	Immune complex assay.
86343	Leukocyte histamine release test (LHR).
86485	Skin test; candida.
86628	Antibody; Candida.
95060	Ophthalmic mucous membrane tests.
95065	Direct nasal mucous membrane test.
0165U	Peanut allergen-specific quantitative assessment of multiple epitopes using enzyme-linked immunosorbent assay (ELISA), blood, individual epitope results and probability of peanut allergy.
0178U	Peanut allergen-specific quantitative assessment of multiple epitopes using enzyme-linked immunosorbent assay (ELISA), blood, report of minimum eliciting exposure for a clinical reaction.

ICD-10 Diagnoses supporting medical necessity (grouped by CPT table)ICD-10

B44.81	Allergic bronchopulmonary aspergillosis
H10.011-H10.45	Conjunctivitis
J30.0-J30.9	Vasomotor and allergic rhinitis
J31.0	Chronic rhinitis
J45.20-J45.998	Asthma
L20.0-L20.9	Atopic dermatitis
L23.0-L23.9	Allergic contact dermatitis
L20.84	Intrinsic (allergic) eczema
L27.2	Dermatitis due to ingested food
T78.00XA-T78.1XXS	Anaphylactic reaction due to food

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ICD-10-CM codes that do not support medical necessity (table excerpt)ICD-10Not Covered

B44.81	Allergic bronchopulmonary aspergillosis
H10.011-H10.45	Conjunctivitis
J30.1-J30.9	Allergic rhinitis
J30.0	Vasomotor rhinitis

ICD-10-CM codes listed in documentICD-10

J31.0	Chronic rhinitis
J45.20-J45.998	Asthma
L20.84	Intrinsic (allergic) eczema
L20.89	Other atopic dermatitis
L20.9	Atopic dermatitis, unspecified
L23.0-L23.9	Allergic contact dermatitis
L25.1-L25.9	Unspecified contact dermatitis
L27.0-L27.9	Dermatitis due to substances taken internally
L50.0	Allergic urticaria
L50.1	Idiopathic urticaria

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CPT codes mentioned in revision history and coding changesCPT

86160	Immunoassay, allergen specific; quantitative
86161	Immunoassay, allergen specific; qualitative
86162	Immunoassay, multiple allergen
86001	Not specified in excerpt (added to not medically necessary table in revision notes)
95070	Removed from policy (per revision notes)
95071	Deleted in 2021 (per revision notes)

Clinical re-evaluation interval for immunotherapy — 3-5 years

Clinical re-evaluation intervalClinical re-evaluation at three to five years to determine need for continuing immunotherapy.

Documentation requirementPeriodic clinical evaluation of treatment benefits must be documented in the medical record.

Record elementsMedical record must include history/physical, test methodology, measured results (wheal/erythema mm or kIU/L), interpretation and plan of care.

Period to assess treatment benefits — 12-24 months

Assessment period to evaluate benefitPeriodic clinical evaluation of treatment benefits; consider other treatment options if no benefit within 12 to 24 months.

Documentation in recordDocument interpretation of test results and how results will be used in the patient’s plan of care.

Clinical decision pointIf no noticeable decrease in symptoms or reduced medication use after 12-24 months, therapy may be considered for change or discontinuation.

Immunotherapy build-up period — approximately 14 to 28 weeks

Typical build-up durationImmunotherapy build-up schedule entails gradually increasing doses over approximately 14 to 28 weeks.

Visit frequencyIn conventional schedules, visit frequency can vary from one to three times per week with a single dose increase each visit.

Accelerated schedulesAccelerated (rush or cluster) schedules administer several injections at increasing doses in a single visit and may increase risk of systemic reactions.

Assessment period for clinical benefit — 12 to 24 months; no reimbursement after two years without apparent benefit

Assessment period for clinical benefitDuration of immunotherapy must be individualized; lack of noticeable clinical improvement after 12 to 24 months may indicate failure.

Reimbursement policyTreatment will not be reimbursed after a two-year period when there is no apparent clinical benefit.

Clinical markers of benefitLook for decrease in symptoms, increased tolerance to offending allergen, and reduction in medication use to justify continuation.

Documentation exceptions — Exceptions for retesting include children and adolescents with documented food allergy requiring follow up

Retesting exceptionsExceptions for retesting include children and adolescents with documented food allergy requiring follow up.

General retesting guidanceRetesting with the same antigen should rarely be necessary; limitations and exceptions are documented in the policy.

Documentation updatesLimitations section updated to include exceptions for retesting; providers should document rationale for repeat testing.

Provider Actions — Documentation, Authorization, and Billing

Prior Authorization

Facility immunotherapy indication requirements

Immunotherapy administered in a medical facility must meet all listed indications: documented positive skin test or serologic evidence of IgE-mediated sensitization to relevant allergens (with diagnoses such as allergic asthma, atopic dermatitis due to dust mite, hymenoptera venom allergy, mold- or perennial/seasonal allergic rhinitis/conjunctivitis), symptoms after natural exposure or life‑threatening insect sting allergy, and failure of avoidance or pharmacologic therapy or unacceptable side effects from pharmacologic therapy. Rapid (rush) desensitization is limited to medication or stinging insect (hymenoptera) sensitivities. Antigen preparation must be performed by clinical staff directly overseen by the physician who examined the patient and who has training and expertise in allergen immunotherapy (e.g., allergist, immunologist, pulmonologist, or otolaryngologist); other specialties must document equivalent training and expertise per ACAAI/AAAI guidance.

Antigens limited to those the member is reasonably exposed to.
Avoidance/pharmacologic therapy must have been tried and proven inadequate or intolerable.

Denial Risk

Not medically necessary tests and services

The following tests, treatments, and services are considered not medically necessary because safety or effectiveness have not been established and may be denied or not reimbursed: testing for antigens such as newsprint, tobacco smoke, dandelion, or the long list of other environmental/food agents; specialized or non‑validated tests and panels (e.g., ALCAT, applied kinesiology/NAET, cytotoxic/ELISA/Act food testing, mediator release test, LRA, MRT, Live Cell Analysis, in vitro IgG testing, many general immune or metabolic assessments); and specific services including non‑FDA sublingual immunotherapy, repository emulsion therapy, ingestion challenge performed at home, intracutaneous desensitization (RIT), food allergenic extract immunotherapy, home administration of immunotherapy, and rush immunotherapy for inhalant allergens.

Complete list of excluded antigen tests and unproven assays (see policy III.A and III.B).
Services considered not medically necessary include non‑FDA sublingual immunotherapy, RIT, repository emulsion therapy, and home administration of allergy immunotherapy.

Documentation Required

Required medical record documentation

Maintain complete medical record documentation for all allergy testing and immunotherapy. Required documentation includes: a complete medical and immunologic history and face‑to‑face physical examination; the medical necessity rationale for the test or therapy; the specific test methodology used; measured reaction sizes (wheal and erythema in mm) for in vivo testing; quantitative results (kIU/L) for specific IgE testing; interpretation of results and how they inform the plan of care; periodic clinical evaluations of treatment benefit (and consideration of alternatives if no benefit within 12–24 months); and clinical re‑evaluation every 3–5 years to determine need for continued immunotherapy.

Document wheal and erythema measurements in millimeters for skin testing.
Document quantitative specific IgE results in kIU/L and how results affect the treatment plan.
Document periodic benefit assessment; if no clear benefit within 12–24 months, treatment may not be reimbursed thereafter.

Documentation Required

Compounding and administration documentation

Maintain and make available standard operating procedures and detailed records for compounding and administration of allergen extracts. Documentation should include SOPs for compounding, training records and assessment results for compounding personnel (written tests, media‑fill or equivalent, gloved fingertip/thumb sampling), annual competency verification, corrective actions when assessments fail, certification reports for primary engineering controls (with corrective actions), temperature logs for storage, individual compounding records for extract prescription sets, and logs of complaints, adverse events, investigations and corrective actions.

Keep written SOPs describing the compounding process and aseptic technique.
Retain training records and annual competency testing results (media‑fill, gloved fingertip/thumb sampling).
Maintain temperature logs, certification reports, compounding records, and adverse event/complaint investigations.

Documentation Required

Provider expertise and training documentation

Documentation must also demonstrate provider expertise and training for immunotherapy preparation and administration. Providers should be allergists, immunologists, pulmonologists, or otolaryngologists with documented training in allergen immunotherapy extract preparation and administration. Other specialties must provide evidence of equivalent training and competency consistent with AAAAI/ACAAI guidance (e.g., extract preparation instructional guides). Immunotherapy should be administered under a physician trained to recognize and treat anaphylaxis and only in facilities equipped to manage anaphylactic reactions.

Document specialty, training, and evidence of competency in extract preparation for the supervising physician.
If non‑allergist specialties perform preparation, include documentation demonstrating training consistent with professional guidance.
Ensure facility readiness to treat anaphylaxis and document emergency preparedness.

Step Therapy

Therapy sequencing and duration requirements

Immunotherapy is indicated only after appropriate sequencing of care: allergy testing demonstrating relevant sensitization plus symptomatic exposure, followed by a trial of avoidance measures and appropriate pharmacologic therapy. Immunotherapy (including subcutaneous or approved sublingual preparations) is appropriate when avoidance and medication do not control symptoms or when medications cause unacceptable side effects. Duration of therapy must be individualized; lack of clinical benefit after 12–24 months supports discontinuation and potential cessation of reimbursement after two years without benefit.

Confirm positive testing (skin or specific IgE) and symptomatic correlation prior to initiating immunotherapy.
Document trials of avoidance and pharmacologic therapy and reasons for failure or intolerance.
Reassess benefit periodically; consider stopping therapy if no noticeable benefit within 12–24 months.

Background

Allergy testing and immunologic evaluation distinguish immediate (IgE‑mediated) hypersensitivity from delayed (cell‑mediated) hypersensitivity. Percutaneous (scratch/prick) testing is typically the preferred initial test for suspected immediate IgE‑mediated allergy; intradermal (intracutaneous) testing is used when greater sensitivity is required or percutaneous tests are negative; in vitro specific IgE blood testing is used when skin testing is contraindicated or unreliable (for example, severe dermatologic disease or inability to stop interfering medications).

The general purpose of allergy testing is to document immunologic sensitivity that correlates with the clinical history and symptoms on exposure so that targeted avoidance, pharmacologic therapy, or allergen immunotherapy may be considered. Allergen immunotherapy administered in a medical facility is medically necessary only when there is positive skin or serologic evidence of specific IgE for relevant allergens, symptoms on natural exposure or life‑threatening insect sting allergy, failure of avoidance/pharmacologic therapy or unacceptable side effects, and antigen preparation and administration under physician oversight with appropriate training and expertise.

Definitions and Key Terms

Percutaneous testing — Scratch, puncture, or prick skin testing (CPT 95004, 95017, 95018) used as the preferred initial test for suspected immediate (IgE-mediated)...

DefinitionPercutaneous testing (scratch, puncture, or prick skin testing) is the preferred initial test for suspected immediate (IgE-mediated) hypersensitivity (CPT 95004, 95017, 95018).

IndicationsUsed as first-line testing for suspected IgE-mediated allergy to inhalants, foods, venoms, drugs, and other immediate-type allergens.

DocumentationResults should include measurement of wheal and erythema in millimeters and interpretation to guide the plan of care.

Intradermal (intracutaneous) testing — Sequential incremental intradermal testing (CPT 95024, 95027, 95028) used when percutaneous tests are negative but strong suspicion remai...

DefinitionSequential incremental intradermal (intracutaneous) testing is used when percutaneous tests are negative but clinical suspicion remains (CPT 95024, 95027, 95028).

Use casesAppropriate for evaluating inhalants, hymenoptera venom, and specific drugs (e.g., penicillins) when increased sensitivity is needed.

Technique guidanceClinician should limit the number of intradermal concentrations to the minimal number necessary; often two concentrations (weaker and stronger) suffice.

In vitro specific IgE testing — Blood tests detecting specific IgE (CPT 86003, 86005, 86008) used when skin testing is contraindicated or unreliable (e.g., severe dermat...)

DefinitionIn vitro specific IgE testing detects specific IgE antibodies in serum (CPT 86003, 86005, 86008) and is used when skin testing is contraindicated or unreliable.

IndicationsIndicated for severe dermatitis, risk of anaphylaxis to skin testing, inability to discontinue interfering medications, uncooperative patients, or when skin testing is negative/equivocal but history is suggestive.

ExamplesCommon methods include RAST, MAST, FAST, ELISA and ImmunoCAP; report quantitative results in kIU/L.

Accelerated (rush or cluster) immunotherapy — Accelerated schedules

DefinitionAccelerated (rush or cluster) immunotherapy are schedules that administer several injections at increasing doses during a single visit to reach maintenance dose more rapidly.

Benefit vs riskThese schedules achieve therapeutic dose earlier but may be associated with increased risk of systemic reactions in some patients.

Appropriate useAccelerated schedules are used selectively; conventional build-up typically spans 14-28 weeks.

Administration under physician supervision in equipped facilities — Allergen immunotherapy supervision requirement

Supervision requirementAllergen immunotherapy should be administered under the supervision of an appropriately trained physician who can recognize and treat anaphylaxis; facilities must be equipped to treat anaphylaxis.

SettingImmunotherapy administration should occur only in facilities equipped to treat anaphylaxis with emergency medications available.

Provider qualificationsSupervising physician must be trained to recognize early symptoms and signs of anaphylaxis and administer emergency treatment.

Immunotherapy preparation personnel/training — Allergen immunotherapy extract preparation should follow the AAAI guide; personnel training and competencies

Preparation standardsAllergen immunotherapy extract preparation should follow AAAAI and USP <797> guidance; personnel must demonstrate aseptic technique, pass written and annual media-fill and gloved fingertip tests, and be overseen by a physician trained in allergen immunotherapy.

Training and testingPersonnel must pass a written aseptic technique test, annually pass media-fill or equivalent and gloved fingertip-thumb sampling tests, and be reinstructed if assessments fail.

RecordkeepingMaintain SOPs for compounding, training records, certification reports for engineering controls, refrigerator logs, compounding records, and complaint/adverse event documentation.

Revision History

03/21coding update

Added J30.0 to ICD-10-CM Code Table 1; minor revision to description of CPT 95070; CPT 95071 noted as deleted in 2021.

09/21annual review

Annual review with references updated; header wording clarified for revision log; criteria and coding reviewed by specialist.

03/22coding update

Removed codes 86160, 86161, and 86162 from the not medically necessary table and added ICD-10 Table 7 listing diagnoses that do not support medical necessity for 86160–86162.

05/22ICD-10 addition

Added ICD-10 codes L20.0, L20.81-L20.83, L24.9, and L30.2 as medically necessary in ICD-10 code table 1.

09/22coding and background update

Added CPT codes 86160, 86161, and 86162 to the medically necessary CPT code list with the qualifier 'when diagnosis code requirements are met per the ICD-10 tables'; added 86001 to the not medically necessary CPT code table; updated background and training information.

09/23annual review

Annual review with description and background updated; coding reviewed and external specialist reviewed the policy.

09/24coding/content update

Added ingestion (oral) challenge testing to criteria; reformatted and updated coding tables and descriptions; removed CPT code 95070 from the policy.

09/25annual reviewLatest

Annual review with description and background updated; minor wording updates and additions (e.g., added 'pulmonologist') with no clinical significance noted.