CurrentArizona Complete HealthPolicy CP.MP.100

Allergy Testing and Therapy (PDF)

Defines medical necessity criteria, not medically necessary services, coding tables (CPT/ICD-10) and documentation requirements for allergy testing and allergen immunotherapy for health plans affiliated with Centene (Arizona Complete Health). This part (1 of 2) includes indications, exclusions, limitations, background, preparation/administration standards, coding implications and revision history through 2020-2023 entries.

Policy Summary

PayerArizona Complete Health

PolicyAllergy Testing and Therapy (PDF)

Policy CodePolicy CP.MP.100

Change TypeCoding, wording and coding-table updates (multiple revisions)

Effective Date

Next Review Date

Key ActionDocument complete history, exam, medical necessity rationale, test methodology and results, and perform periodic clinical evaluation with re-evaluation at 3-5 years to determine need for continuing immunotherapy.

SourceLink

POLICY UPDATE CHANGES

Coding and ICD-10 code ranges expanded/combined; added various ICD-10 codes and CPT codes over multiple revisions (2016-2020) and documentation/frequency clarifications.

Clarified that rapid desensitization is appropriate only for medication and hymenoptera sensitivities.

Revised wording to reference 'non FDA approved sublingual immunotherapy' and note referral to pharmacy benefit (multiple revisions: 01/19, 11/19, 12/19).

Added multiple CPT codes to not medically necessary list (12/19) then later removed some from that list (03/22, 09/22).

Added multiple ICD-10 codes (e.g., J30.0; ranges Z91.010-Z91.018; L20.0, L20.81-L20.83, L24.9, L30.2) to ICD-10 code tables across revisions.

Updated policy language requiring antigen preparation oversight and referenced AAAI instructional guide (09/22).

Updated description and background with no clinical significance (09/23 annual review).

>40CPT/ICD codes listed

3-yearRetesting interval guidance

12-24 monthsImmunotherapy benefit evaluation period

MultipleRevisions recorded (2019-2023)

ICD/CPTCode updates

19+Cited references

Coverage Summary

This policy, Allergy Testing and Immunotherapy (CP.MP.100), defines medical necessity criteria, exclusions, coding tables and documentation requirements for allergy testing and allergen immunotherapy for health plans affiliated with Centene. It applies to members/enrollees being evaluated or treated for immediate (IgE-mediated) and delayed hypersensitivity and includes indications such as allergic rhinitis, asthma, atopic dermatitis and insect venom allergy. The policy is current with a last revision date of 09/23 and records multiple updates from 2016–2023 reflecting coding and editorial changes.

Medical-Necessity Criteria

Not Medically Necessary / Experimental

Per the policy revisions and provider actions, non‑FDA approved sublingual immunotherapy (previously termed sublingual provocative therapy) is considered not medically necessary under this medical benefit and is referenced to the pharmacy benefit for coverage criteria. The policy language was revised to explicitly identify non‑FDA approved SLIT and to direct providers to pharmacy policies for FDA‑approved SLIT products.

Coding

Medically necessary CPT codes (when diagnosis requirements met)CPTCovered

86003	Allergen specific IgE; quantitative or semiquantitative, crude allergen extract, each
86005	Allergen specific IgE; qualitative, multiallergen screen (e.g., 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, include interpretation, specify number of tests
95017	Allergy testing, combination percutaneous and intracutaneous with venoms, immediate type reaction, include interpretation, specify number of tests
95018	Allergy testing, combination percutaneous and intracutaneous with drugs/biologicals, immediate type reaction, include interpretation, specify number of tests
95024	Intracutaneous (intradermal) tests with allergenic extracts, immediate type reaction, include interpretation, specify number of tests

1–10 of 30

1/3

CPT codes considered not medically necessaryCPTNot 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 (ELISA) blood, epitope results and probability of peanut allergy
0178U	Peanut allergen-specific quantitative assessment (ELISA) blood, report of minimum eliciting exposure

ICD-10 codes that support medical necessity (selected tables referenced)ICD-10Covered

B44.81	Allergic bronchopulmonary aspergillosis
H10.01	Conjunctivitis - expanded range H10.01 through H10.45 referenced
J30.0	Vasomotor rhinitis
J30.1-J30.9	Allergic rhinitis (range included)
J31.0	Chronic rhinitis
J45.2*-J45.998	Asthma (ranges include initial encounters and expanded ranges)
L20.0-L20.9	Atopic dermatitis
L23.0-L23.9	Allergic contact dermatitis (range included)
L25.1-L25.9	Unspecified contact dermatitis (range included)
L27.0-L27.9	Dermatitis due to substances taken internally (range included)

1–10 of 25

1/3

CPT codes added to not medically necessary (historical entries)CPTNot Covered

86160	Historical: previously listed as not medically necessary (later removed 03/22 & 09/22 updates)
86161	Historical: previously listed as not medically necessary (later removed 03/22 & 09/22 updates)
86162	Historical: previously listed as not medically necessary (later removed 03/22 & 09/22 updates)
86332	Added to not medically necessary (12/19 revision)
86343	Added to not medically necessary (12/19 revision)
86485	Added to not medically necessary (12/19 revision)
86628	Added to not medically necessary (12/19 revision)
0165U	Added to not medically necessary (12/19 revision)
0178U	Added to not medically necessary (12/19 revision)
86001	Added to not medically necessary CPT code table (09/22 revision)

CPT codes added to medically necessaryCPTCovered

86160	Added to medically necessary CPT code list (09/22 revision) when diagnosis code requirements are met per ICD-10 tables
86161	Added to medically necessary CPT code list (09/22 revision) when diagnosis code requirements are met per ICD-10 tables
86162	Added to medically necessary CPT code list (09/22 revision) when diagnosis code requirements are met per ICD-10 tables

CPT immunotherapy codes (noted editorial changes)CPT

95070	Description minor revision noted (03/21)
95071	CPT 95071 deleted in 2021 (03/21 note)

ICD-10-CM codes added to medically necessary table (Table 1 updates)ICD-10Covered

J30.0	Added to ICD-10-CM Code Table 1 (03/21 revision)
L20.0	Added to ICD-10 code table 1 as medically necessary (05/22 revision)
L20.81	Added to ICD-10 code table 1 as medically necessary (05/22 revision)
L20.82	Added to ICD-10 code table 1 as medically necessary (05/22 revision)
L20.83	Added to ICD-10 code table 1 as medically necessary (05/22 revision)
L24.9	Added to ICD-10 code table 1 as medically necessary (05/22 revision)
L30.2	Added to ICD-10 code table 1 as medically necessary (05/22 revision)
Z88.0-Z88.9	Descriptions revised in ICD-10 Tables 4 & 5 (12/19 revision)
Z91.010-Z91.018	Added to Tables 1 & 4 (10/20 revision)
R06.2	Added to ICD-10-CM code table 1 (11/19 revision)

ICD-10 codes that do not support medical necessity for 86160-86162 (Table 7)ICD-10Not Covered

Table 7 entries

Specific ICD-10 codes listed in new ICD-10 Table 7 (03/22) that do not support medical necessity for CPT 86160-86162; codes enumerated in policy (e.g., B44.81, H10.01-H10.45, J30.1-J30.9, J30.0, J31.0, J45.2-J45.998, L20.84-L20.9, L23.0-L23.9, L25.1-L25.9, L27.0-L27.9, L50.x, L56.x, R06.2, T36.0X5A-T50.995S, T63.001-T63.94, T78.00X-T78.1XXS, T78.49XA-T78.49XS, T80.52XA-T80.52XS, T88.6XXA-T88.6XXS, Z88.0-Z88.9, Z91.010-Z91.018)

Provider Actions & Billing

Documentation Required

Required medical record documentation

Record must include complete medical and immunologic history, face-to-face physical exam, medical necessity rationale, test methodology, measurement of reaction sizes (mm) for in vivo testing, quantitative result (kIU/L) for specific IgE testing, interpretation and how results will be used in the care plan, periodic clinical evaluation of treatment benefits, and clinical re-evaluation at 3-5 years to determine need for continuing immunotherapy.

Measurement of reaction sizes (wheal and erythema) in millimeters for in vivo testing
Quantitative specific IgE results reported in kIU/L for in vitro testing
Documentation of test interpretation and how results inform the patient's care plan
Periodic clinical evaluation of treatment benefits; consider alternative therapy if no benefit within 12–24 months
Clinical re-evaluation at 3–5 years to determine need for continuing immunotherapy

Background & Definitions

Background summarizes that allergy is hypersensitivity to inhaled, ingested, injected, or contact substances and that allergy testing (in vivo and in vitro) is used to identify causative allergens. In vivo tests include percutaneous (scratch/prick/puncture), intradermal (sequential/incremental), patch/photo testing, inhalation bronchial challenge and supervised ingestion challenges; in vitro testing includes quantitative/semiquantitative specific IgE assays (e.g., RAST, ELISA, ImmunoCAP). Indications for immunotherapy include evidence of specific IgE to clinically relevant allergens with symptoms such as allergic asthma, allergic rhinitis/conjunctivitis, stinging insect hypersensitivity and select cases of atopic dermatitis; venom immunotherapy is indicated for anaphylaxis after insect sting with documented venom sensitivity. Rapid desensitization (rush) is reserved for medication and hymenoptera sensitivities when urgent use of the agent is required and must occur under strict physician monitoring. Build‑up schedules are individualized: conventional build‑up typically over ~14–28 weeks with 1 dose escalation per visit; accelerated (rush/cluster) schedules give several increasing doses in a single visit and carry increased systemic reaction risk. Duration of therapy is individualized; lack of clinical benefit after 12–24 months is a presumption of failure and therapy will not be reimbursed after a 2‑year period without benefit. Personnel preparing extracts must meet aseptic compounding and competency standards per AAAAI/USP guidance, and immunotherapy must be administered in facilities equipped and staffed to recognize and treat anaphylaxis.

Term	Definition
Percutaneous testing
Scratch, puncture, or prick skin testing for immediate type reactions (CPT 95004, 95017, 95018).
Intradermal testing
Intracutaneous tests performed when increased sensitivity is needed (CPT 95024, 95027, 95028).
Rapid desensitization / Rush immunotherapy
Accelerated desensitization schedules providing several injections at increasing doses in a single visit; medically necessary only for medication or hymenoptera sensitivities per policy.
Non-FDA approved sublingual immunotherapy
Sublingual provocative therapy referenced to pharmacy benefit; termed non-FDA approved in policy revisions.

Medicare Determinations

Type	Name/Description	Number	Effective
LCD
Local coverage determination: allergy testing (L34313, L33417, L33261, L36402)


LCD
Local coverage determination: immunotherapy (L32553)

Revision History

01/16created

Policy created; specialist reviewed.

02/17clarified

Clarified that rapid desensitization is appropriate only for medication and hymenoptera sensitivities and added ICD-10 codes for insect allergy status to CPT 95180 (rapid desensitization).

04/17revised

Removed statement in documentation requirements about medical necessity for in vitro vs in vivo testing; frequency limitations removed as state-specific (CMS NCCI MUE applied in absence).

Policy Summary

PayerArizona Complete Health

PolicyAllergy Testing and Therapy (PDF)

Policy CodePolicy CP.MP.100

Change TypeCoding, wording and coding-table updates (multiple revisions)

Effective Date

Next Review Date

SourceLink

On This Page

Prior Authorization

State-specific unit limitations

Unit limitations for allergy testing and treatment are determined by state-specific guidelines in the provider fee schedule. If state-specific guidance is not available, CMS Medicaid/Medicare NCCI MUE limits are applied.

See state provider fee schedule for specific unit limits
If no state rules, apply CMS NCCI MUE limits

Billing Rule

Photo tests/patch test reporting

When patch/photo testing are performed in the same session, follow the reporting rule: if photo patch tests (95052) are performed with patch/application tests (95044) in the same session, report only the photo patch tests; if photo tests (95056) are performed with patch/application tests (95044), report only the photo tests.

Affected codes: 95052, 95044, 95056

Billing Rule

Ingestion challenge unit

Ingestion challenge testing is allowed once per patient encounter regardless of the number of items tested. Report the initial 120 minutes with CPT 95076 and each additional 60 minutes with CPT 95079 (each additional 60 minutes reported separately in addition to the primary procedure).

Affected codes: 95076, 95079
One allowed service per patient encounter; 95076 = initial 120 minutes; 95079 = each additional 60 minutes (report separately)

Documentation Required

Immunotherapy administration setting and supervision

Allergen immunotherapy should be administered under the supervision of an appropriately trained physician in facilities equipped to recognize and treat anaphylaxis. Personnel preparing extracts must demonstrate aseptic technique and documented competency, with training, written testing, annual media-fill/glove fingertip testing, and maintenance of training records.

Affected codes: 95115, 95117, 95144, 95165, 95180
Facility readiness and ability to treat anaphylaxis required
Personnel must meet aseptic technique and competency testing requirements and maintain training records

Denial Risk

Total serum IgE testing limitations

Total serum IgE testing (CPT 82785) is not appropriate for most general allergy evaluations and should only be billed for specific indications such as allergic bronchopulmonary aspergillosis (ABPA), select immunodeficiencies (e.g., hyper-IgE syndromes), or when evaluating for omalizumab; serial repeat testing is subject to medical review.

Affected code: 82785
Reserve for ABPA, select immunodeficiencies, IgE myeloma/pemphigoid, or omalizumab evaluation
Serial/repeat total IgE testing will be medically reviewed

Billing Rule

Evaluation and management billing with immunotherapy

Evaluation and management (E/M) services may be separately reimbursed on the same day as allergen immunotherapy only when a significant, separately identifiable E/M service is performed and documented.

Document the separately identifiable E/M service to support same-day reimbursement

Documentation Required

Immunotherapy extract preparation oversight

Antigens must be prepared by clinical staff directly overseen by the physician who examined the patient and who has training and expertise in allergen immunotherapy. Training and competency expectations reference the AAAAI Allergen Immunotherapy Extract Preparation Instructional Guide and include demonstrated aseptic technique, written testing, annual media-fill or equivalent testing, gloved fingertip/thumb sampling, and maintenance of training and assessment records.

Oversight requirement: physician who examined the patient must directly oversee antigen preparation
Reference: AAAAI Allergen Immunotherapy Extract Preparation Instructional Guide for training expectations
Personnel expectations include written test, annual media-fill, gloved fingertip testing, and retained training/assessment records

Documentation Required

Refer sublingual immunotherapy to pharmacy benefit

Non-FDA approved sublingual immunotherapy (sublingual provocative therapy) is referenced to the pharmacy benefit for coverage criteria and is considered non-FDA approved per policy revisions.

Refer non-FDA approved SLIT formulations to the pharmacy benefit
Only FDA-approved SLIT products are recommended per AAAAI/AAAI guidance

01/19added

Added CPT 86008 to in vitro testing and CPT table 1; added ICD-10 code B44.81 and T88.6XXA-T88.6XXS to ICD-10 tables; multiple CPTs (86160-86162, 86332, 86343, 86485, 86628, 0165U, 0178U) noted as added to not medically necessary table in revisions around this period.

11/19 - 12/19revised

Revised wording in not medically necessary section from 'sublingual provocative therapy' to 'non FDA approved sublingual immunotherapy' and added reference to refer SLIT to pharmacy benefit; removed a background statement about in vitro testing appropriateness; added R06.2 to ICD-10-CM table 1.

10/20revised

Added '(scratch, puncture, prick)' to percutaneous test descriptions; added multiple CPT codes (86160-86162, 86332, 86343, 86485, 86628, 0165U, 0178U) to not medically necessary CPT Table 2; revised ICD-10 descriptions including Z88.x ranges and added Z91.010-Z91.018.

03/21added

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

03/22revised

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

05/22added

Added ICD-10 codes (L20.0, L20.81-L20.83, L24.9, L30.2) to ICD-10 Code Table 1 as medically necessary.

09/22revised

Updated policy language requiring antigen preparation oversight by clinical staff directly overseen by the examining physician with training and expertise in allergen immunotherapy; added CPT codes 86160-86162 to medically necessary list when ICD-10 diagnosis requirements are met; added 86001 to not medically necessary table.

09/23reviewedLatest

Annual review: updated description and background with no clinical significance; coding reviewed; external specialist reviewed.