CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLAB023

Diagnosis of Idiopathic Environmental Intolerance - Clinical Payment and Coding Policy

This BCBSNM Clinical Payment and Coding Policy governs reimbursement for laboratory tests used to diagnose idiopathic environmental intolerance and related profiling; it applies to providers submitting claims under BCBSNM plans. Providers should consult plan documents for product-specific coverage.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyDiagnosis of Idiopathic Environmental Intolerance - Clinical Payment and Coding Policy

Policy CodePolicy CPCPLAB023

Change TypeRevised (clarity and literature review)

Effective DateAug 15, 2023

Next Review DateN/A

Key ActionProviders must submit accurate documentation and may be requested to provide additional documentation; claims are subject to review.

SourceLink

POLICY UPDATE CHANGES

Reimbursement information revised for clarity and literature review updated.

multipleNon‑reimbursable test types

10 codesProcedure code unit limits

2023-08-15Policy effective

Coverage Criteria

Non-reimbursable tests and contexts

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Diagnosis confirmation testing: Laboratory tests designed to confirm the diagnosis of idiopathic environmental illness are not reimbursable in all circumstances.

Volatile solvents / organic acids / organophosphates screening: Screening of blood, saliva, serum, plasma, urine, and/or stool samples for volatile solvents, organic acids, and organophosphates is not reimbursable in all circumstances.

Phthalates and parabens profiling: Profiling of phthalates and parabens using a blood, serum, plasma, saliva, urine, and/or stool sample is not reimbursable in all circumstances.

Chlorinated pesticide profiling (asymptomatic individuals): For asymptomatic individuals, profiling of chlorinated pesticides, including DDE and DDT, using a blood, serum, plasma, saliva, urine, and/or stool sample is not reimbursable.

Profiling and functional testing in asymptomatic or general encounters: In asymptomatic individuals and/or during general encounters without abnormal findings, testing of blood, serum, plasma, saliva, urine, and/or stool samples for carnitine sufficiency, oxidative stress and antioxidant sufficiency, detoxification adequacy, methylation sufficiency status, lipoic acid and CoQ10 sufficiency, and/or intestinal hyperpermeability are not reimbursable.

Vitamin, mineral, and nutritional analysis (asymptomatic/general encounters): In asymptomatic individuals and/or during general encounters without abnormal findings, testing of blood, serum, plasma, saliva, urine, and/or stool samples for vitamin sufficiency, mineral sufficiency, and/or nutritional analysis are not reimbursable.

Metals testing (asymptomatic/general encounters): In asymptomatic individuals and/or during general encounters without abnormal findings, testing blood, serum, urine, cerebrospinal fluid, fingernails, hair, and/or stool samples for metals are not reimbursable.

Breath hydrogen and/or methane testing — multiple indications: The use of a breath hydrogen and/or breath methane test is not reimbursable to assess or diagnose idiopathic environmental intolerance; food allergies and sensitivities; carbohydrate sensitivity or intolerance; bacterial overgrowth (including but not limited to small intestinal bacterial overgrowth [SIBO]); digestive disorders; constipation, diarrhea, or flatulence; neurological/neuromuscular disorders; rosacea; obesity; or as part of a wellness visit and/or general encounter without abnormal findings.

Procedure codes note: Inclusion of a procedure code in the list does not guarantee coverage or reimbursement eligibility; code edit protocols and plan terms apply.

Coding and Unit Limits

Procedure code unit limitsCPTCovered

83918	Organic acids; total, quantitative, each specimen — max 2 units per DOS
83919	Organic acids; qualitative, each specimen — max 1 unit per DOS
83921	Organic acid, single, quantitative — max 2 units per DOS
82127	Amino acids; single, qualitative, each specimen — max 1 unit per DOS
82136	Amino acids, 2 to 5 amino acids, quantitative, each specimen — max 2 units per DOS
82139	Amino acids, 6 or more amino acids, quantitative, each specimen — max 2 units per DOS
84585	Vanillylmandelic acid (VMA), urine — max 1 unit per DOS
83150	Homovanillic acid (HVA) — max 1 unit per DOS
83497	Hydroxyindolacetic acid (5-HIAA) — max 1 unit per DOS
82656	Elastase, pancreatic (EL-1), fecal, qualitative or semi-quantitative — max 1 unit per DOS

Unit limits per date of service

83918Organic acids; total, quantitative, each specimen — max 2 units per date of service

83919Organic acids; qualitative, each specimen — max 1 unit per date of service

83921Organic acid, single, quantitative — max 2 units per date of service

82127Amino acids; single, qualitative, each specimen — max 1 unit per date of service

82136Amino acids, 2 to 5 amino acids, quantitative, each specimen — max 2 units per date of service

82139Amino acids, 6 or more amino acids, quantitative, each specimen — max 2 units per date of service

84585Vanillylmandelic acid (VMA), urine — max 1 unit per date of service

83150Homovanillic acid (HVA) — max 1 unit per date of service

83497Hydroxyindolacetic acid (5-HIAA) — max 1 unit per date of service

82656Elastase, pancreatic (EL-1), fecal, qualitative or semi-quantitative — max 1 unit per date of service

Documentation and Claims Review

Documentation Required

Documentation, coding, and claims review – submit accurate documentation and respond to requests

Providers must submit accurate documentation of services performed and code claims using valid HIPAA-approved code sets and industry coding guidelines. Claims are subject to code edit protocols and review; upon request providers should submit any additional documentation to support the claim. Plan documents and provider contracts govern in the event of a conflict with this policy.

Submit claims using valid HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC, DRG) and follow industry coding guidelines (AMA CPT, UB Editor, CMS NCCI/CCI, etc.).
Claims are subject to code edit protocols and review against benefit terms, provider contract language, medical policies, clinical payment and coding policies, and coding software logic.
If requested, promptly provide additional documentation to support medical necessity and coding.

Definitions and Plan Precedence

Plan documents / provider contract precedence

Definition'Plan documents' include, but are not limited to, Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents.

Precedence — Plan documentsIf a conflict arises between this Clinical Payment and Coding Policy and any plan document under which a member is entitled to Covered Services, the plan document will govern.

Precedence — Provider contractsIf a conflict arises between this policy and any provider contract pursuant to which a provider participates in and/or provides Covered Services, the provider contract will govern.

Provider responsibilityProviders are responsible for submission of accurate documentation and should review plan documents for eligible coverage for services rendered.