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Allergen Testing
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Defines Blue Cross Blue Shield New Mexico's reimbursement stance and criteria for in‑vitro and skin allergen testing and related laboratory procedures for covered members and providers.
When performed on the same day as skin prick testing, specific IgE in-vitro allergy testing is not reimbursable.
Added CPT code 95004 to the policy coding list.
For individuals with signs or symptoms of allergies, basophil activation flow cytometry testing and in‑vitro testing of IgG, IgA, IgM, and/or IgD are not reimbursable.
A prior guidance-only Reimbursement Information item #1 was removed.
Coverage Criteria and Exclusions
Primary coverage criteria and exclusions
Covered or excluded as specified below when billing for in‑vitro and related allergy testing:
ALL of the following
ALL of the following
- Testing is limited to allergens selected based on the individual’s history, physical examination, and environment.
- Provider limits testing to no more than up to 20 allergen‑specific IgE antibody tests per year.
ANY of the following
- Individual has moderate to severe asthma.
- Individual has signs or symptoms of allergic bronchopulmonary aspergillosis.
ALL of the following
- Annual re‑testing of the same food allergen(s) to monitor for allergy resolution is permitted when there was an initial positive food allergen result.
ANY of the following
- Specific IgE in‑vitro testing performed on the same day as skin prick testing.
- Routine re‑testing for the same allergens in the absence of a new clinical presentation (except where specifically allowed above).
- Antigen Leukocyte Antibody test / ALCAT.
- Basophil activation flow cytometry testing for individuals with signs or symptoms of allergies.
- In‑vitro testing of IgG, IgA, IgM, and/or IgD for individuals with signs or symptoms of allergies.
- In‑vitro allergen testing using bead‑based epitope assays (e.g., VeriMAP Peanut Dx).
- In‑vitro testing using qualitative specific IgE multi‑allergen screens that do not identify specific allergens.
Reimbursement exclusions and rules
Operational reimbursement rules, recent edits, and combined exclusions:
Procedure Codes and Limits
| 95004 | Added to policy coding list |
Documentation, Billing, and Prior Authorization
Documentation and claims coding: submit accurate documentation and use valid code sets
Providers must submit accurate documentation of services performed and submit claims using valid code combinations from HIPAA-approved code sets. Claims should be coded according to industry standard coding guidelines (for example: Uniform Billing Editor, AMA CPT Assistant, HCPCS, ICD-10-CM/PCS, NDC, DRG guidelines, CMS NCCI Policy Manual, and CCI table edits). Claims are subject to code edit protocols and may be reviewed; upon request providers should submit additional documentation to support the claim.
- Submit claims using valid code combinations from HIPAA-approved code sets.
- Code claims per industry-standard guidelines (CPT, HCPCS, ICD-10, NCCI, CCI edits, etc.).
- Be prepared to provide additional documentation upon request; claims are subject to code edit protocols and review.
Prior authorization / reimbursement note: same‑day testing non‑reimbursement and CPT 95004 added
Specific IgE in‑vitro allergy testing performed on the same day as skin prick testing is not reimbursable; additionally, CPT code 95004 was added to the policy coding list.
- Do not bill for specific IgE in‑vitro allergy testing when it is performed the same day as skin prick testing—those in‑vitro tests are not reimbursable.
- Note that CPT code 95004 (percutaneous allergy skin tests) was added to the policy coding list; verify appropriate use and coding when billing skin testing.
Key Definitions and Non-reimbursable Tests
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