Arizona Complete Health Allergy Testing Coverage Update

Coverage and Medical Necessity Criteria

Allergy testing — general medical necessity

Covered when ALL of the following are met

General testing criteria: Performed as part of a complete diagnostic evaluation by a licensed practitioner acting within their scope of practice to perform allergy and immunology services; antigens chosen are reasonably possible exposures for the member; and the chosen test and units follow listed code options and unit limits per year (see CPT Code Table 1 for allowed tests and CPT/unit guidance).

Includes percutaneous, intradermal, skin endpoint, in vitro, patch and photo testing as specified in CPT Code Table 1

Allergen immunotherapy — coverage criteria

Covered when ALL of the following are met

Immunotherapy indications: Positive skin test or serologic evidence of an IgE-mediated antibody to allergens that cause allergic asthma, dust mite atopic dermatitis, hymenoptera allergic reactions, mold-induced allergic rhinitis, perennial allergic rhinitis, or seasonal allergic rhinitis/conjunctivitis; symptoms after natural exposure to the allergen or a life‑threatening insect sting allergy; avoidance or pharmacologic therapy does not control symptoms or causes unacceptable side effects; and antigens are prepared by an allergist, immunologist, or otolaryngologist who has examined the patient.

Rapid desensitization/rush immunotherapy is medically necessary only for medication or hymenoptera sensitivities. For FDA‑approved sublingual immunotherapy refer to the pharmacy policy.

Immunotherapy treatment duration and assessment

Conditions for continuing therapy

Duration and stopping rule: Therapy duration must be individualized. A presumption of failure can be made when, after 12–24 months of therapy, the patient does not experience a noticeable decrease in symptoms, an increase in tolerance to the offending allergen, or a reduction in medication usage. Treatment will not be reimbursed after a 2‑year period when there is no apparent clinical benefit; re‑evaluate clinically at 3–5 years to determine need to continue.12-24 months

Clinical benefit must be documented in the medical record; major risk is anaphylaxis and administration must meet safety requirements.

Medically necessary testing and immunotherapy

Covered procedures and services

Medically necessary procedures: CPT procedures listed in CPT Code Table 1 (including in‑vivo tests, in‑vitro specific IgE assays, challenge testing, and professional immunotherapy services) are considered medically necessary when supported by corresponding ICD‑10 diagnoses listed in ICD‑10‑CM Code Tables 1–6.

See CPT Code Table 1 and ICD‑10 Code Tables for mapping of procedures to allowed diagnoses; professional services codes (e.g., 95115, 95117, 95144–95170, 95180) apply when indicated.

Not medically necessary

Not medically necessary procedures

Not medically necessary tests: CPT procedures listed in CPT Code Table 2 (for example 86332, 86343, 86485, 86628, 95060, 95065, 0165U, 0178U) are considered not medically necessary because safety or effectiveness have not been established.

Also includes specific unlisted and new technology allergen assays enumerated in CPT Code Table 2.

Immunotherapy schedules and duration

Treatment scheduling and duration

Build-up schedule: Immunotherapy build‑up entails administration of gradually increasing doses over approximately 14–28 weeks; conventional schedules typically increase dose once per visit with visit frequency 1–3 times weekly; accelerated (rush/cluster) schedules administer multiple increasing doses in a single visit and may increase systemic reaction risk.14-28 weeks

Schedule must be individualized based on patient risk and response.

Duration and discontinuation: Duration must be individualized; if after 12–24 months there is no noticeable symptom improvement, increased tolerance, or reduction in medication use, therapy may be presumed to have failed; treatment will not be reimbursed after 2 years without apparent clinical benefit.12-24 months; reimbursement stopped after 2 years

Document clinical benefit to support continuation.

Safety requirements

Safety and administration

Administration and supervision: Allergen immunotherapy should be administered under the supervision of an appropriately trained physician in facilities equipped to recognize and treat anaphylaxis.

Evaluation and management (E/M) codes are separately reimbursable the same day only when a significant, separately identifiable service is performed.

Coverage criteria and not medically necessary items

Policy tables and revision history define covered vs not medically necessary tests and immunotherapy; the full criteria are in earlier sections

Not medically necessary antigen testing: Testing for cornstarch, cotton, formaldehyde, and smog is listed as not medically necessary.

Added to the not medically necessary antigen list in the revision history.

CPTs in not medically necessary table: Several CPT codes were added to the not medically necessary CPT Table 2 (86160, 86161, 86162, 86332, 86343, 86485, 86628, 0165U, 0178U); some codes (86160–86162) were later removed from the not medically necessary table and ICD‑10 Table 7 was added to specify diagnoses that do not support medical necessity for those codes.

See revision history and CPT Code Table 2 for details.

Sublingual immunotherapy handling: Sublingual immunotherapy is designated as non‑FDA‑approved in this policy and coverage/criteria are referred to the pharmacy benefit.

Providers should consult pharmacy benefit criteria for FDA‑approved sublingual products and non‑FDA sublingual protocols.

The policy lists an extensive set of antigens and testing modalities that are considered not medically necessary because safety or effectiveness have not been established. Examples of excluded antigens include newsprint, tobacco smoke, dandelion, orris root, phenol, alcohol, sugar, yeast, grain mill dust, soybean dust (unless occupational exposure documented), wool (unless continuous exposure to sheep or unprocessed wool), marigold, honeysuckle, fiberglass, green tea, chalk, cornstarch, cotton, formaldehyde, and smog.

The policy also enumerates numerous alternative, unvalidated, or experimental test methods and panels that are not medically necessary, including but not limited to ALCAT (automated food allergy testing), applied kinesiology/NAET, anti-Fc epsilon receptor antibody testing, blood/urine/stool micronutrient assessments, candidiasis testing, hair chemical analysis, chronic urticarial index testing, Clifford materials reactivity testing, electrodermal testing, electromagnetic sensitivity testing, environmental cultures/chemicals, ELISA/Act qualitative antibody testing, food immune complex assays (FICA), in vitro metal allergy testing, leukocyte/basophil histamine release tests, Live Cell Analysis, lymphocyte function assays, LRA/MRT/MRT-type mediator release tests, and VeriMAP Peanut Diagnostic™.

Additionally, the policy designates a range of services related to testing and immunotherapy as not medically necessary, such as desensitization with non-recommended extracts (e.g., poison ivy/oak/sumac, certain whole body extracts), bacterial vaccine desensitization, food allergenic extract immunotherapy, provocative/neutralization therapies (including Rinkel Test), repository emulsion therapy, non-FDA approved sublingual immunotherapy, urine autoinjection, home administration of immunotherapy, ingestion challenge food testing performed at home, and intradermal testing for food allergies.

CPT procedures explicitly listed as not medically necessary are documented in CPT Code Table 2. Examples from that table include 86332 (immune complex assay), 86343 (leukocyte histamine release test), 86485 (skin test; candida), 86628 (antibody; Candida), 95060 (ophthalmic mucous membrane tests), 95065 (direct nasal mucous membrane test), 0165U and 0178U (peanut epitope ELISA-based assessments).

Providers should reference the CPT Code Table 2 mapping in the policy when determining coverage for these specific procedures and confirm whether a billed CPT is designated not medically necessary in the current policy version.

Testing for cornstarch, cotton, formaldehyde, and smog is explicitly listed in the policy as not medically necessary and was added to the exclusions in the revision history.

Claims for testing that target these specific antigens may be denied under the policy unless they meet separate, explicit medical necessity criteria documented elsewhere in the member's record.

The policy identifies many additional antigens and a broad set of alternative or unvalidated diagnostic tests and services as not medically necessary. These include a wide variety of unconventional assays and procedures (see exclusions) such as ALCAT, applied kinesiology/NAET, electrodermal testing, MRT/LRA/mediator release assays, in vitro metal allergy testing, VeriMAP Peanut Diagnostic™, food immune complex assays, and numerous other immunologic and metabolic assessments.

It also lists disallowed services related to immunotherapy—examples include provocative and neutralization therapies, repository emulsion therapy, non-FDA approved sublingual immunotherapy, urine autoinjection, home administration of immunotherapy, intracutaneous desensitization procedures for food, and rush immunotherapy for inhalant allergens.

The policy identifies a set of CPT codes in CPT Code Table 2 that are not medically necessary. Table 2 entries include codes such as 86332, 86343, 86485, 86628, 95060, 95065, 0165U, and 0178U.

Revision history shows that additional CPT codes were added to the not medically necessary table during updates; providers should confirm the current table when determining coverage and billing.

The policy revision history documents that several CPT codes were added to the not medically necessary CPT Table 2 and later revised. Specifically, codes 86160, 86161, 86162, 86332, 86343, 86485, 86628, 0165U, and 0178U were placed in the not medically necessary table in prior revisions, and subsequently 86160–86162 were removed from that table in a later update.

Because codes have been added and removed over time, billing and prior authorization should be checked against the current policy tables and the provider fee schedule to ensure correct designation at the time of service.

CPT and ICD-10 Coding Tables

Covered CPT Codes for in vivo testingCPTCovered

95004	Percutaneous allergy test
95017	Percutaneous allergy test
95018	Percutaneous allergy test
95024	Intracutaneous (intradermal) testing
95027	Skin endpoint titration / intradermal
95028	Sequential and incremental intracutaneous testing
95044	Patch testing
95052	Photo patch test(s)
95056	Photo tests

Covered CPT Codes for in vitro testingCPTCovered

86003	Allergen specific IgE; single allergen
86005	Allergen specific IgE; multiple allergen
86008	Allergen specific IgE; qualitative/quantitative

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.
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, sequential and incremental, with venoms, immediate type reaction, including test interpretation and report, specify number of tests.
95018	Allergy testing, any combination of percutaneous and intracutaneous, 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, specify number of tests.
95027	Intracutaneous tests, sequential and incremental, with allergenic extracts for airborne allergens, immediate type reaction, including test interpretation and report, specify number of tests.
95028	Intracutaneous tests with allergenic extracts, delayed type reaction, including reading, specify number of tests.
95044	Patch or application test(s) (specify number of tests).

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Not Medically Necessary CPT CodesCPTNot Covered

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 ELISA, blood, individual epitope results and probability of peanut allergy.
0178U	Peanut allergen-specific quantitative assessment... report of minimum eliciting exposure for a clinical reaction.

ICD-10 Diagnoses supporting or not supporting medical necessityICD-10

B44.81	Allergic bronchopulmonary aspergillosis.
H10.01 - H10.45	Conjunctivitis (expanded range).
J30.1 - J30.9	Allergic rhinitis.
J30.0	Vasomotor rhinitis.
J31.0	Chronic rhinitis.
J45.2 - 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.

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CPT codes referenced in revision historyCPT

86160	specified in policy as not medically necessary (was later removed from NMN table)
86161	specified in policy as not medically necessary (was later removed from NMN table)
86162	specified in policy as not medically necessary (was later removed from NMN table)
86332	listed in not medically necessary CPT Table 2
86343	listed in not medically necessary CPT Table 2
86485	listed in not medically necessary CPT Table 2
86628	listed in not medically necessary CPT Table 2
0165U	listed in not medically necessary CPT Table 2
0178U	listed in not medically necessary CPT Table 2
86008	added to in vitro testing and CPT code table 1

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ICD-10 codes added in revisionsICD-10

B44.81	added to ICD-10 code table 1
R06.2	added to ICD-10-CM code table 1
J30.0	added to ICD-10-CM Code Table 1

ICD-10 rangesICD-10

Z91.010-Z91.018

ICD-10 code range added to Tables 1 & 4

Inhalation bronchial challenge unit definition

Unit definitionOne unit = the best of three measurements (three measures per determination).

Measurement examplesCommon measures include spirometry and prolonged post-exposure evaluation of bronchospasm; three measures are performed and the best is accepted as the unit.

Unit countingEach set of three measurements constitutes one unit of service for inhalation bronchial challenge testing.

Provider Responsibilities, Documentation, and Billing Guidance

Billing Rule

Code-based coverage requirement

Coverage is determined by CPT/HCPCS codes listed in the policy code tables. Providers must bill only codes that are included in the "medically necessary" code table for covered services; codes listed in the "not medically necessary" table will be denied. Verify that the CPT code submitted matches the actual service performed and the policy's coverage status for that code.

Refer to CPT Code Table 1 for procedure codes considered medically necessary and CPT Code Table 2 for procedure codes considered not medically necessary.
Do not bill codes from the not medically necessary table; these codes are explicitly excluded from coverage.

Prior Authorization

Check prior authorization and code membership

Some CPT codes in this policy require prior authorization (PA) or have been added/removed in past revisions. Providers must check the payer's PA system or the member's benefit information before performing services to confirm current PA requirements and that the codes are listed as eligible for coverage.

Background and Scope

Allergy testing and immunotherapy encompass multiple modalities used to identify IgE‑mediated sensitivity and to modify immune responses. Percutaneous (scratch/puncture/prick) testing with standardized extracts (CPTs such as 95004, 95017, 95018) is the preferred initial test for immediate hypersensitivity when clinically appropriate, while intradermal testing/skin endpoint titration (CPTs 95024, 95027, 95028) is used when greater sensitivity is required or to establish starting immunotherapy doses.

When skin testing is contraindicated or impractical, in vitro specific IgE testing (e.g., RAST, ELISA, ImmunoCAP; CPTs 86003, 86005, 86008) provides quantitative or qualitative measures of allergen-specific IgE and informs diagnosis and treatment planning. Immunotherapy involves repeated administration of identified allergens to achieve clinical improvement; safety considerations include the risk of anaphylaxis, requiring administration under appropriate medical supervision in facilities equipped to manage systemic reactions.

Key Definitions and Test Descriptions

Percutaneous testing

DefinitionPercutaneous testing: scratch, puncture, or prick skin testing using standardized allergenic extracts (CPT 95004, 95017, 95018).

Clinical rolePreferred initial test for immediate hypersensitivity and performed under medical supervision due to small but significant anaphylaxis risk.

Related codesCPT codes listed: 95004, 95017, 95018 (include test interpretation and reporting; specify number of tests).

Intradermal testing / skin endpoint titration

DefinitionIntradermal testing / skin endpoint titration: intracutaneous testing (CPT 95024, 95027, 95028) used when increased sensitivity is needed after negative percutaneous tests.

Use casesAppropriate for suspected IgE-mediated reactions to inhalants, hymenoptera venoms, and certain drugs; endpoint titration may determine starting immunotherapy dose.

Policy Revision Timeline

10/20codes_added

Multiple CPT codes were added to the not medically necessary CPT Table 2 (86160, 86161, 86162, 86332, 86343, 86485, 86628, 0165U, 0178U).

11/19icd10_added_and_sublingual_revised

R06.2 was added to ICD-10-CM Code Table 1; wording revised to describe sublingual therapy as 'non FDA approved sublingual immunotherapy' and referral to the pharmacy benefit for coverage criteria; a background statement about in vitro testing was removed.

03/22codes_removed_and_icd10_table_added

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Allergy Testing and Immunotherapy