CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLABO23

Diagnosis of Idiopathic Environmental Intolerance laboratory testing reimbursement

Governs reimbursement and coding limits for laboratory tests related to diagnosing idiopathic environmental intolerance for BCBSNM members; providers should review plan documents for product-level applicability.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyDiagnosis of Idiopathic Environmental Intolerance laboratory testing reimbursement

Policy CodePolicy CPCPLABO23

Change TypeRevised reimbursement details and literature review

Effective DateAug 15, 2023

Next Review Date

Key ActionSubmit accurate documentation upon request; claims are subject to plan documents, provider contracts, medical policies, CPCPs, and coding review.

SourceLink

POLICY UPDATE CHANGES

Reimbursement information revised for clarity and references updated; new literature review added when policy became effective 8/15/2023.

All circumstancesTests not reimbursable

Multiple specimen typesScreening (multiple specimens)

Breath testsBreath tests

Unit limitsUnit limits

2023-08-15

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Coverage Criteria and Non-Reimbursable Tests

Non-reimbursable tests and limits

The following tests and specimen-based screenings are not reimbursable or are subject to per‑date‑of‑service unit limits. Providers should review applicable plan documents for product-level applicability and note that claims are subject to adjudication and may be audited.

Reimbursement exclusions and limits apply as follows:

Non‑reimbursable tests (general)

Laboratory tests designed to confirm the diagnosis of idiopathic environmental illness are not reimbursable in all circumstances.
Screening of blood, saliva, serum, plasma, urine, and/or stool samples for volatile solvents, organic acids, and organophosphates is not reimbursable in all circumstances.
Profiling of phthalates and parabens using blood, serum, plasma, saliva, urine, and/or stool samples is not reimbursable in all circumstances.

Non‑reimbursable tests in asymptomatic individuals or general encounters

Profiling of chlorinated pesticides (including DDE and DDT) using blood, serum, plasma, saliva, urine, and/or stool samples is not reimbursable for asymptomatic individuals.
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 is not reimbursable 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 is not reimbursable 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 is not reimbursable in asymptomatic individuals and/or during general encounters without abnormal findings.

Breath testing exclusions

Use of breath hydrogen and/or breath methane testing is not reimbursable to assess or diagnose idiopathic environmental intolerance.
Breath hydrogen and/or methane testing is not reimbursable to assess or diagnose food allergies and sensitivities, bacterial overgrowth including small intestinal bacterial overgrowth (SIBO), carbohydrate sensitivity or intolerance, digestive disorders, constipation, diarrhea, flatulence, neurological/neuromuscular disorders, rosacea, obesity, or when performed as part of a wellness visit or general encounter without abnormal findings.

Coding limits (per‑date‑of‑service): Specific CPT laboratory codes are subject to per‑date‑of‑service unit maximums as listed in the coding section; providers must adhere to those unit limits when submitting claims.

Claims adjudication and plan variability: Not all requirements apply to each product; plan documents govern applicability. Claims are subject to code edit protocols, benefit coverage, provider contract terms, medical policies, CPCPs, and coding software logic; providers may be asked to submit additional documentation.

CPT Codes, Unit Limits, and Coding Details

Lab CPT codes with unit limitsCPTCovered

83918	Organic acids; total, quantitative, each specimen
83919	Organic acids; qualitative, each specimen
83921	Organic acid, single, quantitative
82127	Amino acids; single, qualitative, each specimen
82136	Amino acids, 2 to 5 amino acids, quantitative, each specimen
82139	Amino acids, 6 or more amino acids, quantitative, each specimen
83150	Homovanillic acid (HVA)
83497	Hydroxyindolacetic acid (5-HIAA)
82656	Elastase, pancreatic (fecal), qualitative or semi-quantitative

83918 unit maximum

CPT 83918Maximum 2 units per date of service

83919 unit maximum

CPT 83919Maximum 1 unit per date of service

83921 unit maximum

CPT 83921Maximum 2 units per date of service

82127 unit maximum

Documentation, Claims, and Coding Submission Requirements

Documentation Required

Documentation and claims review

Providers are responsible for submitting accurate documentation of services performed. Claims are subject to code edit protocols and claim review including benefit coverage, provider contract language, medical policies, CPCPs, and coding software logic; upon request, providers may be asked to submit additional documentation.

Submit accurate documentation of services performed when filing claims.
Be prepared to provide additional documentation if requested during claim review.

Billing Rule

Coding submission requirements

Submit claims using valid, HIPAA‑approved code sets and code appropriately per industry coding guidelines (for example CPT, HCPCS, ICD‑10, UB standards and CMS coding/NCCI guidance).

Plan Documents and Governing Coverage

Plan documents and precedence

Plan documents (examples)Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents

Governing ruleIf a conflict exists between a CPCP and any plan document under which a member is entitled to Covered Services, the plan document will govern

Provider contractsIf a conflict exists between a CPCP and any provider contract, the provider contract will govern