ModifiedBlue Cross Blue Shield of VermontPolicy 1.02.VT201

Allergy Testing, Including Selected Blood, Serum and Cellular Testing and Toxicity Testing Corporate Medical Policy

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This policy governs coverage of specified allergy testing and selected blood, serum, cellular, and toxicity-related tests. It identifies testing that may be medically necessary, not medically necessary, or investigational for members when the stated clinical criteria are met.

Policy Summary

PayerBlue Cross Blue Shield of Vermont

PolicyAllergy Testing, Including Selected Blood, Serum and Cellular Testing and Toxicity Testing

Policy CodePolicy 1.02.VT201

Change TypeModified

Effective DateMay 1, 2026

Last ReviewFeb 1, 2026

Next Review DateFeb 1, 2027

Key ActionObtain prior approval for KIT D816V variant analysis billed under CPT 81273.

SourceLink

POLICY UPDATE CHANGES

Medical necessity criteria for KIT D816V mutational analysis to aid diagnosis of suspected systemic mastocytosis were added.

CPT code 81273 was added to the coding table as requiring prior approval.

CPT code 83516, when specified as ALCAT testing, was changed from not medically necessary to investigational.

The coding table was updated to include CPT 81273 and revise instructions for CPT 83516.

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ModifiedBlue Cross Blue Shield of VermontPolicy 1.02.VT201

Allergy Testing, Including Selected Blood, Serum and Cellular Testing and Toxicity Testing Corporate Medical Policy

Customize your policy alerts

Sign up for bcbsvermont Policy 1.02.VT201 alerts

Get alerted when Policy 1.02.VT201 changes without checking for updates manually.

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Policy Summary

PayerBlue Cross Blue Shield of Vermont

PolicyAllergy Testing, Including Selected Blood, Serum and Cellular Testing and Toxicity Testing

Policy CodePolicy 1.02.VT201

Change TypeModified

Effective DateMay 1, 2026

Last ReviewFeb 1, 2026

Next Review DateFeb 1, 2027

Key ActionObtain prior approval for KIT D816V variant analysis billed under CPT 81273.

SourceLink

POLICY UPDATE CHANGES

Medical necessity criteria for KIT D816V mutational analysis to aid diagnosis of suspected systemic mastocytosis were added.

CPT code 81273 was added to the coding table as requiring prior approval.

CPT code 83516, when specified as ALCAT testing, was changed from not medically necessary to investigational.

The coding table was updated to include CPT 81273 and revise instructions for CPT 83516.

13Covered testing categories

2Not medically necessary services

40+Investigational or unproven examples

7Listed procedure codes

1Code requiring prior approval

4/dayDaily limit for CPT 86160

Medical Necessity and Coverage Criteria

Covered allergy testing modalities

The following testing may be considered medically necessary when clinically indicated.

Diagnostic and treatment-directed allergy testing: Epicutaneous (scratch, prick, or puncture) or intradermal allergy testing for IgE-mediated reactions to inhalants, foods, Hymenoptera stinging insects, or specific drugs, including penicillins and macromolecular agents; patch testing for contact allergic dermatitis or certain drug-induced cutaneous reactions; photo patch testing for photoallergy or photosensitization; ingestion/oral double-blind challenge testing for suspected IgE-mediated hypersensitivity when history and physical findings are suggestive but skin testing is negative or equivocal; exercise challenge testing for exercise-induced bronchospasm; or Skin Endpoint Titration to determine the starting immunotherapy dose for members highly allergic to inhalants or Hymenoptera venom allergy.

Skin Endpoint Titration is not appropriate for routine testing. Covered testing must serve the diagnostic or immunotherapy-planning purposes specified in the policy.

Drug challenge testing

Drug provocation or challenge testing may be considered medically necessary only when ALL criteria are met.

ALL of the following: The member has a history of allergy to the particular drug; treatment with that drug class is essential; and no effective alternative drug is available.

The test is intended to diagnose suspected IgE-mediated hypersensitivity.

Bronchial challenge testing

Bronchial challenge testing with methacholine, histamine, or antigens may be considered medically necessary when ANY criterion applies.

ANY of the following: Testing identifies causative or provocative occupational or other allergens for which skin testing is not reliable; confirms asthma when the member is symptomatic but has abnormal pulmonary function test results and no response to a bronchodilator; evaluates new allergens or substantiates the role of allergens in a member with significant symptoms; or evaluates occupational asthma.

Testing may use methacholine, histamine, or antigens.

Allergen-specific IgE immunoassays

Allergen-specific IgE immunoassays may be considered medically necessary for inhalant or food allergy when percutaneous IgE testing cannot be performed because ANY listed circumstance applies.

ANY of the following reasons: Severe dermatographism, ichthyosis, or generalized atopic dermatitis; use of long-acting antihistamines, tricyclic antidepressants, or medications that create undue risk if discontinued; an uncooperative member with mental or physical impairment; an infant or child who will not tolerate skin testing or for whom severe reaction is a concern; serial testing of a child with documented food allergies to assess readiness for oral food challenge; adjunctive laboratory evaluation of disease activity in allergic bronchopulmonary aspergillosis or certain parasitic diseases; evaluation of cross-reactivity between insect venoms; unusually high anaphylaxis risk from skin testing, including when an unusual allergen lacks a licensed skin-test extract; or inconclusive direct skin testing.

Testing modalities include RAST, MAST, PRIST, RIST, FAST, modified RAST, VAST, ELISA, and ImmunoCAP. Intradermal testing should generally be used instead of in-vitro testing for definitive diagnosis of anaphylactic sensitivities to stinging insects and drugs.

Lymphocyte transformation testing

Lymphocyte transformation testing may be considered medically necessary when ANY criterion applies.

ANY of the following indications: Medical surveillance of beryllium sensitivity or chronic beryllium disease; evaluation of suspected congenital or acquired immunodeficiency affecting cell-mediated immunity; or prediction of allograft compatibility in the transplant setting.

Lymphocyte transformation testing for allergies or other hypersensitivities is experimental and investigational.

Selected serum, immune, and molecular tests

The following laboratory tests may be considered medically necessary for the specified diagnostic or management purposes.

Specified diagnostic or management purposes: Total serum IgE for known or suspected allergic bronchopulmonary aspergillosis, certain stages of HIV infection, drug-induced interstitial nephritis, eczema and hyper-IgE syndrome, graft-versus-host disease, parasitic diseases, immune deficiency diseases such as Hyper-IgE syndrome or Wiskott-Aldrich syndrome, or IgE myeloma; complement antigen testing for diagnosis and management of inflammatory conditions; immunoglobulin subclass testing such as IgG1, IgG2, IgG3, or IgG4 for diagnosis and management of autoimmune disorders; or KIT D816V mutational analysis to aid diagnosis of suspected systemic mastocytosis when compatible symptoms are present.

Routine total IgE or immunoglobulin testing is not supported solely for nonspecific allergic symptoms.

Not medically necessary

The following services are considered not medically necessary.

ANY of the following services: Routine allergy retesting that will not change clinical management; or Leukocyte Histamine Release Testing.

Leukocyte Histamine Release Testing is not medically necessary.

Investigational allergy and toxicity testing

The following allergy, toxicity, cellular, and environmental sensitivity tests or interventions are unproven and therefore investigational; the list may not be all-inclusive.

ANY of the following services: Advanced Cell Test qualitative antibody testing; adrenal stress index; alpha-gal allergy testing; anti-Fc epsilon receptor antibodies; ALCAT; applied or iridology kinesiology; basophil tests; basophil histamine release assay; body chemical analysis; Candida hypersensitivity testing; chemical analysis of body tissues such as hair; serum chlorinated pesticide testing; circulating immune complexes to foods; component-resolved diagnostics; conjunctival challenge testing; cytokine or cytokine receptor assays; cytotoxic food testing; electrodermal diagnostic testing including VEGA; electrodermal acupuncture; eosinophil cationic protein testing; Food Immune Complex Assay; hair analysis; HEMOCODE Food Intolerance System; LHRT; lymphocyte function assay; mediator release testing; muscle strength testing after allergen ingestion; nasal mucous membrane challenge; passive transfer or Prausnitz-Kustner testing; provocation-neutralization testing; pulse or reaginic pulse testing; Rebuck Skin Window testing; SAGE test; saliva testing; serum allergen-specific IgG or IgG4 testing; serum IgA or IgG testing for allergy; Rinkel skin titration; sublingual provocative neutralization testing and hormone treatment; urine autoinjection or autogenous urine immunization; venom-blocking antibodies; volatile chemical panels; laboratory testing for electromagnetic sensitivity; laboratory testing for multiple chemical sensitivity or idiopathic environmental intolerance; laboratory testing designed to affirm idiopathic environmental intolerance; and treatments for idiopathic environmental intolerance, including IVIG, neutralizing therapy of chemical or food extracts, avoidance therapy, elimination diets, and oral nystatin.

The investigational list may not be all-inclusive.

Complement antigen testing exception

CPT 86160 is not medically necessary for all diagnoses except when it may be indicated for diagnosis and management of inflammatory conditions; maximum 4 units per day.

CPT 86160 exception: The test is used for diagnosis and management of an inflammatory condition and does not exceed 4 units per day.≤ 4 units per day

CPT 86160 is otherwise not medically necessary.

Routine allergy retesting that will not change clinical management is considered not medically necessary.

Lymphocyte transformation testing for evaluating allergies or other hypersensitivities is considered experimental and investigational. Coverage may be considered for specified uses such as beryllium sensitivity surveillance, suspected cell-mediated immunodeficiency, or transplant compatibility assessment.

The listed unproven allergy, toxicity, cellular, chemical-sensitivity, and idiopathic-environmental-intolerance services are investigational. Examples include ALCAT, cytotoxic food testing, electrodermal testing, hair or saliva analysis, provocative-neutralization testing, serum allergen-specific IgG or IgG4 testing, testing for electromagnetic or multiple chemical sensitivity, and related treatments such as IVIG, neutralizing therapy, avoidance therapy, elimination diets, and oral nystatin. The list may not be all-inclusive.

Specific IgG antibody testing by RAST or ELISA is not supported for diagnosis or treatment of allergic disease when immunodeficiency is not suspected. The policy states that specific IgG measurement has no diagnostic value for atopic allergic disease.

CPT 83516, when specified as ALCAT testing, is considered investigational.

CPT 86001 (allergen-specific IgG quantitative or semiquantitative testing, each allergen) is not medically necessary for all diagnoses.

CPT 86343 (Leukocyte Histamine Release Test) is not medically necessary for all diagnoses.

CPT 95199, when specified as cytotoxic testing for allergies, is not medically necessary for all diagnoses and will suspend for medical record review.

Routine allergy retesting that will not change clinical management is considered not medically necessary.

The Leukocyte Histamine Release Test (LHRT) is considered not medically necessary.

Routine total serum IgE testing does not provide additional diagnostic information when clinical signs of allergic disease are evident. Normal IgE levels also do not exclude allergic disease in infants or children; testing may have a role only for specified conditions such as allergic bronchopulmonary aspergillosis, hyper-IgE syndromes, certain parasitic or immune-deficiency diseases, and other listed indications.

Routine quantitative measurement of total serum IgG, IgA, and IgM has not established clinical utility in the diagnosis and management of allergic disease because these levels are not typically altered by allergic diseases.

Measurement of specific IgG antibodies has no diagnostic value in managing atopic allergic disease. Evidence is insufficient to support specific IgG testing by RAST or ELISA for diagnosis or treatment of allergic disease, except in the setting of suspected immunodeficiency.

CPT 82787 (immunoglobulin subclasses, such as IgG1, IgG2, IgG3, or IgG4) is not medically necessary for all diagnoses, except that it may be indicated for the treatment and management of autoimmune disorders.

CPT Coding and Coverage Status

Prior Approval RequiredCPTCovered

81273

KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (eg, mastocytosis), gene analysis, D816 variant(s)

Not medically necessary except stated autoimmune-disorder exceptionCPTNot Covered

82787

Immunoglobulin subclasses (eg, IgG1,2, 3, or 4

InvestigationalCPTExperimental

83516

than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method [When specified as ALCAT]

Not medically necessary for all diagnosesCPTNot Covered

86001

Allergen specific IgG quantitative or semiquantitative, each allergen

Not medically necessary except for diagnosis and management of inflammatory conditions; limit 4 units per dayCPTNot Covered

86160

Complement; antigen, each component

Not medically necessary for all diagnosesCPTNot Covered

86343

Leukocyte histamine release test (LHR)

Not medically necessary for all diagnoses; suspends for medical record reviewCPTNot Covered

95199

Unlisted allergy/clinical immunologic service or procedure [when specified as cytotoxic testing for allergies]

CPT 86160 Daily Unit Limit

CodeCPT 86160 — Complement; antigen, each component.

Daily limitMaximum 4 units per day.

ExceptionMay be indicated for diagnosis and management of inflammatory conditions; otherwise not medically necessary for all diagnoses.

Authorization, Documentation, and Provider Guidance

Prior Authorization

Prior Approval Required for KIT D816V Analysis

Obtain prior approval before performing KIT D816V mutational analysis for evaluation of suspected systemic mastocytosis.

CPT 81273 — KIT D816V gene analysis; prior approval is required.

Documentation Required

Medical Records Required for Cytotoxic Testing Review

For cytotoxic allergy testing, submit the member’s relevant medical records when requested. The claim will suspend for medical record review before determination.

CPT 95199 — unlisted allergy/clinical immunologic service when specified as cytotoxic testing for allergies.
Provide documentation supporting the service and its clinical context.

Policy Background

Allergy testing is used to identify allergens responsible for allergic reactions, including immunoglobulin E (IgE)-mediated and contact-mediated reactions. Food allergy is generally IgE-mediated and may cause symptoms ranging from mild reactions to life-threatening anaphylaxis, while food intolerance is generally nonimmune-mediated. Testing and immunotherapy planning are covered only for the specific clinical purposes described in this policy.

Definitions and Terminology

Allergy Testing

PurposeTesting used to determine what types of allergens cause a particular allergy.

Common approachA small amount of allergen is typically introduced under the skin by scratching or puncturing the skin.

AssessmentThe skin is observed for a reaction.

Allergy Treatment or Immunotherapy

PurposeTreatment of allergies intended to produce tolerance to the relevant allergens.

Dosage approachIncreasing amounts of allergic extract are injected over the course of treatment.

Treatment endpoint

Policy Summary

PayerBlue Cross Blue Shield of Vermont

PolicyAllergy Testing, Including Selected Blood, Serum and Cellular Testing and Toxicity Testing

Policy CodePolicy 1.02.VT201

Change TypeModified

Effective DateMay 1, 2026

Last ReviewFeb 1, 2026

Next Review DateFeb 1, 2027

Key ActionObtain prior approval for KIT D816V variant analysis billed under CPT 81273.

SourceLink

On This Page

Billing Rule

Confirm Benefit Eligibility and Plan Terms

Confirm that the service is covered under the applicable subscriber contract, certificate, or employer benefit plan before rendering it. Contract and plan language takes precedence over conflicting medical policy provisions.

Review applicable terms, limitations, conditions, exclusions, and plan-specific restrictions.
ASO employer plan documents may determine benefits when the member is enrolled through an ASO group.

Unsupported block type: denial_risk

Denial Risk

Investigational or Unproven Testing

The following allergy tests, laboratory tests, and related interventions are unproven and investigational. Claims for these services or interventions may not be covered.

Advanced cell test (ACT) qualitative antibody testing using ELISA methodology; adrenal stress index; alpha-gal allergy testing; anti-Fc epsilon receptor antibody testing; antigen leukocyte cellular antibody test (ALCAT).
Applied kinesiology; basophil tests; basophil histamine release assay (BHRA); body chemical analysis; Candida hypersensitivity test; chemical analysis of body tissues, including hair; chlorinated pesticides in serum; circulating immune complexes to foods.
Component-resolved diagnostics; conjunctival challenge test; cytokine and cytokine receptor assay; cytotoxic food tests, including Bryan’s Test and Metabolic Intolerance test; electrodermal diagnostic testing (VEGA test); electrodermal acupuncture; eosinophil cationic protein (ECP) test; food immune complex assay (FICA).
Hair analysis; HEMOCODE Food Intolerance System; iridology; kinesiology and applied kinesiology; leukocyte histamine release test (LHRT); lymphocyte function assay; mediator release test (MRT); muscle strength testing or measurement after allergen ingestion; nasal mucous membrane challenge test.
Passive transfer or P-X (Prausnitz-Kustner) test; provocation-neutralization tests; pulse or reaginic pulse test; Rebuck Skin Window test; SAGE test for food delayed hypersensitivity; saliva testing; serum IgG or IgG4 allergen-antibody testing; serum IgA or IgG testing for allergy; skin titration (Rinkel method).
Sublingual provocative neutralization testing and treatment with hormones; urine autoinjection; venom blocking antibodies; volatile chemical panels; laboratory testing for electromagnetic sensitivity syndrome/disorder; laboratory testing for multiple chemical sensitivity syndrome.
Laboratory testing designed to affirm idiopathic environmental intolerance and treatments for that condition, including IVIG, neutralizing therapy of chemical and food extracts, avoidance therapy, elimination diets, and oral nystatin.

Denial Risk

Policy Noncompliance or Audit Findings

Blue Cross VT may audit providers and facilities for compliance with this medical policy. If an audit identifies noncompliance, Blue Cross VT may recoup all non-compliant payments.

Maintain documentation demonstrating compliance with applicable policy requirements.
Non-compliant payments may be subject to recoupment.

Note

Verify Member-Specific Benefits

Verify benefits for the specific member before providing a service because coverage may vary by group or individual contract and may include exclusions or different benefit rules.

NEHP/ABNE and Federal Employee Program members may have different benefits; contact the applicable customer service department or consult the FEP Service Benefit Plan Brochure.
For ASO members, consult the employer’s benefit plan documents or customer service department.
Not all groups are required to follow Vermont legislative mandates; member contract language takes precedence when there is a conflict.

Billing Rule

Code-Specific Noncoverage or Investigational Status

Apply the policy instructions associated with the billed CPT code. Services designated investigational or not medically necessary may be denied, and applicable review or approval requirements must be satisfied.

CPT 82787 — immunoglobulin subclasses: necessary for all diagnoses except may be indicated for treatment and management of autoimmune disorders.
CPT 83516 — when specified as ALCAT: investigational.
CPT 86001 — allergen-specific IgG: not medically necessary for all diagnoses.
CPT 86160 — complement antigen: not medically necessary for all diagnoses except may be indicated for diagnosis and management of inflammatory conditions; limit 4 units per day.
CPT 86343 — leukocyte histamine release test: not medically necessary for all diagnoses.
CPT 95199 — when specified as cytotoxic allergy testing: not medically necessary for all diagnoses and suspends for medical record review.

Injections continue until the patient becomes tolerant of the allergens.

Environmental Illness

DefinitionA physiologic reaction to an exogenous agent.

Possible routesThe agent may be ingested, inhaled, or contacted through the skin.

Response typeThe response may be immunologic or non-immunologic.

Food Allergy

DefinitionA reaction to a specific food protein.

Typical mechanismGenerally an immunoglobulin E (IgE)-mediated reaction.

SeverityReactions may range from mild symptoms to life-threatening anaphylaxis.

Food Intolerance

DefinitionA physiologic reaction triggered by a particular food.

MechanismThe reaction is not immune-mediated.

ExampleLactose intolerance is an example of food intolerance.

IgG-Mediated Food Sensitivity Testing

PurposeTesting for food-specific IgG antibodies intended to identify food intolerance or delayed food reactions.

Underlying premiseThe testing is based on the premise that elevated IgG antibody levels indicate food intolerances.

Policy positionSpecific IgG antibody testing has no diagnostic value for management of atopic allergic disease; evidence is insufficient to support RAST or ELISA testing for diagnosis or treatment of allergic disease without suspected immunodeficiency.

ALCAT Testing

Billing codeALCAT testing is billed under CPT 83516.

Test descriptionCPT 83516 describes a qualitative or semiquantitative, multiple-step infectious-agent antibody or infectious-agent antigen method when specified as ALCAT.

Policy positionALCAT testing is investigational.