CurrentBlue Cross Blue Shield - MassachusettsPolicy 264

Diagnosis and Management of Idiopathic Environmental Intolerance or Clinical Ecology prn.pdf

Defines coverage for laboratory tests and treatments for idiopathic environmental intolerance (IEI) / multiple chemical sensitivities for Commercial and Medicare members of Blue Cross Blue Shield Massachusetts; includes inpatient/outpatient prior authorization requirements and states investigational status for tests and treatments.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyDiagnosis and Management of Idiopathic Environmental Intolerance or Clinical Ecology prn.pdf

Policy CodePolicy 264

Change TypeAnnual reviewreferences updated

Effective DateSep 1, 2022

Next Review Date

Key ActionPrecertification/preauthorization is required for all products if services described in this policy are performed inpatient.

SourceLink

POLICY UPDATE CHANGES

9/2022 annual policy review updated literature through September 2022 and added references; policy statements unchanged.

12/2019 policy updated with literature review through December 1, 2019; references added; policy statements unchanged.

7/2014 wording in statement on treatment modified for clarification.

All tests and treatments

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Coverage Summary

Defines coverage for laboratory tests and treatments for Idiopathic Environmental Intolerance (IEI) / Multiple Chemical Sensitivities for Commercial and Medicare members of Blue Cross Blue Shield Massachusetts; includes inpatient/outpatient prior authorization requirements and states investigational status for tests and treatments. Coverage stance: Not covered (investigational). Effective date: 2022-09-01. Last review: 2022-09-01.

Policy metadata

Policy number264

PayerBlue Cross Blue Shield - Massachusetts

Effective date2022-09-01

Last review2022-09-01

Coverage stanceInvestigational / Not covered (tests and treatments for idiopathic environmental intolerance are investigational)

SubjectIdiopathic Environmental Intolerance (Multiple Chemical Sensitivities) — diagnostic testing and treatments

Medical-Necessity Criteria

Diagnostic tests for idiopathic environmental intolerance

Covered when ALL of the following are met:

Laboratory tests designed to affirm the diagnosis of idiopathic environmental intolerance are considered INVESTIGATIONAL.

Treatments for idiopathic environmental intolerance

Treatments for idiopathic environmental intolerance, including but not limited to IVIg, neutralizing therapy of chemical and food extracts, avoidance therapy, elimination diets, and oral nystatin (to treat Candida) are INVESTIGATIONAL.

Inpatient prior authorization

For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.

Provider Actions & Billing Impact

Prior Authorization

Inpatient precertification required

Precertification/preauthorization is required for all products if services described in this policy are performed inpatient.

Prior Authorization

Outpatient prior authorization may be required

Prior authorization might be required for outpatient services described in this policy for certain products; providers must check product-specific rules.

Providers must check product-specific rules for outpatient prior authorization requirements.

Documentation Required

Code reporting

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

Coding

CPT CodesCPT

There is no specific CPT code for this service.

General coding notemixed

ICD-10 (unspecified)

Inclusion or exclusion of a code does not constitute coverage; providers should report services using up-to-date procedure, revenue, and diagnosis codes including modifiers where applicable.

Background

Idiopathic environmental intolerance is characterized by recurrent, nonspecific symptoms the patient attributes to low-level exposures to chemical, biologic, or physical agents. Reported symptoms are variable and commonly involve the central nervous system, respiratory and mucosal irritation, or gastrointestinal complaints. Despite frequently debilitating symptoms, no specific or consistent abnormalities are found on laboratory or diagnostic testing, and objective diagnostic criteria and evidence-based treatments are lacking.

Evidence is insufficient: studies using existing criteria have not reliably distinguished exposure from placebo, controlled treatment studies are lacking, and overall diagnostic accuracy and treatment efficacy data are inadequate to support coverage of tests or therapies for IEI.

Idiopathic environmental intolerance (IEI): Recurrent nonspecific symptoms the patient believes are provoked by low levels of exposure to chemical, biologic, or physical agents; also known as multiple chemical sensitivities.

Investigational: Procedures, tests, or treatments without sufficient evidence of efficacy or diagnostic accuracy to be considered covered.

Revision History

2014-07clarified

Wording in statement on treatment modified for clarification.

2019-12-01revised

Policy updated with literature review through December 1, 2019; references added. Policy statements unchanged.

2022-09revised

Annual policy review updated literature through September 2022 and added references; policy statements unchanged.