Allergy Skin and Challenge Testing
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Coverage criteria for in vivo allergy testing (skin tests, patch tests, bronchial and food challenges, serial dilution endpoint titration, and repeat testing) for Blue Cross Blue Shield of North Carolina members; describes when testing is medically necessary, investigational tests, and billing/coding guidance.
No material clinical or coverage changes in this revision.
Coverage Criteria
Medically necessary coverage
Covered when ALL of the following are met: testing is medically necessary and ordered by a physician. Specific modalities covered include:
See child/adult repeat testing criteria separately
Initial standard series: T.R.U.E. TEST® includes 35 common allergens; policy permits standard series (36) plus up to 6 targeted allergens initially.
Use advantageous when high likelihood of severe reaction to specific agents
Covered scenarios and historical limits
Covered when ALL of the policy-specified conditions and limits are met (historical notes and edits over time):
Documentation required for medical necessity; individual review
In‑vitro testing criteria relocated to related policy in 4/1/19
Added to policy 5/7/07 and reiterated in billing/coding guidance
Added/clarified in updates 12/10/13, 6/12/12, 3/9/18 and later notices
The following allergy tests are considered investigational and are not covered: Nasal Challenge Test (nasal mucous membrane provocation), Leukocyte Histamine Release Test (LHRT), Rebuck Skin Window Test, Passive Transfer (Prausnitz–Kustner) Test, Cytotoxic Food (Leukocytotoxic) Testing, Provocation/Provocation Neutralization (Rinkel) Testing, Conjunctival Challenge Testing, Mediator Release Test (MRT), and the Pediatric Allergy Solutions (PAS) Macroarray Test. These tests are listed as investigational because published evidence does not establish sufficient diagnostic accuracy or clinical utility for routine use.
Policy history documents multiple examples of tests moved to investigational/not covered status over time and the rationale for those decisions. Notable historical changes include addition of nasal challenge testing, mediator release tests, antigen leukocyte cellular antibody (ALCAT) automated food testing, in vitro metal allergy testing, and others to the "not covered" list; the policy record also documents evolving limits for patch testing and specific IgE screening thresholds with associated implementation dates.
The policy history shows discrete implementation notes: for example, the description of in vivo versus in vitro testing was clarified on 5/7/07; greater than 35 patch tests required individual review (10/12/09) and the patch testing limit was increased to 42 units (6/12/12) with >42 tests requiring documentation and individual consideration (7/1/13). Diagnostic screen limits for specific IgE were later revised from 36 to 20 allergen-specific antibodies effective 5/11/18 (policy notice 3/9/18).
Allergy testing will be denied when the medical criteria and guidelines in this policy are not met. In particular, repeat skin testing with multiple antigens is not medically necessary when the repeat-testing conditions listed in the covered section are not satisfied, and will be subject to denial if documentation does not support medical necessity.
When testing exceeds the policy’s stated unit or test limits (for example, patch testing beyond the historical thresholds of >35 or later >42 units), documentation of medical necessity is required; lack of adequate documentation may result in individual consideration or denial. Providers should ensure medical records include the clinical history and justification required by the policy before submission.
Repeat skin testing with multiple antigens is specifically described as not medically necessary when the repeat-testing criteria in the covered section are not met. The policy explains acceptable repeat-testing scenarios (for children who develop new sensitivities, adults with dramatic symptom changes, or after 3–5 years of venom immunotherapy) and states that repeats outside those indications are not covered (12/10/13 and subsequent updates).
This statement serves as a historic policy position: unless the documented clinical circumstances meet the policy’s repeat-testing criteria, repeat skin testing using multiple antigens will be considered not medically necessary and may be denied. Providers requesting repeat testing should document how the case meets one of the policy-specified indications.
Coding and Unit Limits
| 86001 | added to Billing/Coding section (historical note) |
| 86003 | added to Billing/Coding section (historical note) |
| 86005 | added to Billing/Coding section (historical note) |
| 86343 | added to Billing/Coding section (historical note) |
| 86353 | added to Billing/Coding section (historical note) |
| 83516 | added to Billing/Coding section (historical note) |
| 83518 | added to Billing/Coding section (historical note) |
| 83519 | added to Billing/Coding section (historical note) |
| 83520 | added to Billing/Coding section (historical note) |
| 95017 | added to Billing/Coding section (historical note) |
Provider Actions and Documentation
Coding and medical necessity review — document records on request
Inclusion of a procedure or CPT code in the Billing/Coding section does not guarantee reimbursement; BCBSNC may request medical records to determine medical necessity and supporting documentation for services billed.
- Providers should be prepared to submit medical records, letters of support, and full clinical documentation when requested to substantiate medical necessity.
- Codes listed (e.g., 83518, 83519, 86353, 95004, 95017–95018, 95024, 95027–95028, 95044, 95052, 95056, 95060, 95065, 95070, 95076, 95079, J7999) are examples and do not ensure payment.
Individual review/prior authorization for testing beyond routine limits
Testing that exceeds the routine policy limits (for example, patch testing beyond the standard unit limit or specific IgE testing beyond the diagnostic screen limit) requires individual review and documentation of medical necessity; prior authorization or individual consideration may be required.
- Greater-than-limit services (e.g., >35 historically, later >42 patch tests, or expanded specific IgE panels) will be reviewed on an individual consideration basis.
- Documented justification must be submitted to support testing beyond the stated routine limits.
Document a thorough history and be ready to provide records
Ensure a thorough patient history and clear documentation of medical necessity are completed and available before ordering allergy tests; BCBSNC may request these records for review.
- The medical record should document the medical necessity, based on the patient’s history, for each allergy test ordered.
- When records are requested, include all specific information needed to make a medical necessity determination; letters alone are often insufficient.
Provider alert — review policy updates and implementation notes
Refer to policy update alerts (implementation notes) for provider considerations — for example, historical changes to patch-test unit limits and diagnostic screen thresholds that affect when individual review is required.
- Policy history documents changing limits (e.g., patch testing limits increased from 35 to 42 units; specific IgE screen limits revised).
- Providers should check current policy versions and implementation notes when planning comprehensive or non-routine testing.
Documentation and medical record requirements — justify each test
Before ordering tests beyond routine unit limits, document a complete history and clinical justification for each test; BCBSNC may request medical records to verify necessity and will review excess testing individually.
- For patch testing exceeding policy thresholds, include documentation of prior evaluation/treatment and how dermatitis interferes with activities of daily living when applicable (see criteria for >42 tests).
- Records should include prior test results, treatments attempted, and reasons why expanded testing is clinically needed.
Medical necessity documentation for excess patch tests (> policy limits)
When more patch tests than the policy-specified limit are performed, document medical necessity clearly; lack of documentation may lead to denial or require individual consideration.
- Historical thresholds cited include >35 patch tests (earlier) and >42 patch tests (later); documentation must explain why expanded testing is required (persistent ACD after prior evaluation/treatment or other listed criteria).
- Include evidence of prior avoidance, prior positive tests, prior treatments, and functional impact on the patient’s daily living.
Denial triggers — noncompliance with medical criteria
Tests will be denied when the medical criteria and guidelines in the policy are not met; repeat skin testing with multiple antigens may be considered not medically necessary when covered-section criteria are not satisfied.
- Repeat skin testing with multiple antigens is not covered unless it meets the specific repeat-testing criteria (e.g., pediatric new sensitizations, adults with dramatic symptom changes, post-venom immunotherapy evaluation).
- Services lacking documented medical necessity or not meeting covered criteria are subject to denial.
Documentation required for tests beyond unit limits — document excess units and rationale
If performing tests that exceed unit limits (for example, more than 35 historically or more than 42 patch tests per later revisions), explicitly document medical necessity for each excess unit; BCBSNC will require this documentation during individual review.
- Billing for greater-than-limit patch testing should be accompanied by medical records demonstrating why standard series were insufficient and why expanded testing meets policy criteria.
- Failure to provide adequate documentation for tests beyond unit limits can result in denial or nonpayment.
Definitions
Background
Allergy testing is performed to identify offending agents so that avoidance measures, pharmacologic treatment, or immunotherapy can be directed appropriately. In vivo testing includes skin procedures such as scratch/prick/puncture (epicutaneous), intradermal, patch testing, and food or bronchial challenge tests; these methods are used for immediate and delayed hypersensitivity evaluation and, in select cases, to guide immunotherapy initiation.
The policy recognizes variants of intradermal testing such as Serial Dilution Endpoint Titration (SDET/SET/IDT) — described as an eligible variant of conventional intradermal testing that differs primarily in the number of dilutions administered — and notes clinical uses including difficult-to-diagnose asthma (bronchial challenge) and double-blind food challenge testing when indicated.
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