Allergy Skin and Challenge Testing
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Policies governing coverage of in vivo allergy skin tests and challenge procedures (e.g., prick, intradermal, patch, bronchial and food challenges) for Blue Cross Blue Shield of North Carolina members; excludes in vitro testing which is covered under a separate policy.
No material clinical or coverage changes in this revision.
Coverage Criteria for Allergy Skin and Challenge Testing
Covered Allergy Testing Modalities
Covered when ALL of the following are met
From policy statement: covered when medically necessary and ordered by a physician.
Policy notes the number of tests may vary; inhalant evaluation may require up to 70 prick/puncture tests followed by up to 40 intradermal tests.
Standard panels include 35–36 allergens; six additional targeted allergens may be performed initially.
Procedure involves paired application with UVA exposure as described in policy.
Reserved for difficult-to-evaluate asthma cases.
Food may be lyophilized/blended or placed in a capsule per policy description.
Eligible as a variant of conventional intradermal testing, used when high likelihood of severe reaction or specific clinical need.
Policy lists specific pediatric and adult indications for repeat testing.
Covered and conditional testing
Policy specifies conditions where expanded testing is considered medically necessary and when tests are eligible, with thresholds for number of tests and requirements for documentation and individual review.
Policy requires both parts (a and b) and documentation for >42 tests; requests reviewed individually.
Policy history: threshold increased from 36 to 42; documentation required for over‑threshold testing.
Policy implementation updates clarify SDET is an eligible variant of intradermal testing.
Policy revisions (2013–2015) describe pediatric and adult repeat testing indications.
See policy implementation updates describing the change and migration of in vitro criteria to a separate policy.
The policy lists specific allergy tests that are considered investigational and not covered. These include the Nasal Challenge Test (nasal mucous membrane provocation), the Leukocyte Histamine Release Test (LHRT), the Rebuck Skin Window Test, the Prausnitz‑Kustner (passive transfer) test, Cytotoxic Food (Leukocytotoxic) Testing, Provocation‑Neutralization (Rinkel) Testing, and Conjunctival Challenge Testing. The policy states the rationale for exclusion for each test (for example, utility not established, insufficient evidence of diagnostic accuracy, obsolete or replaced by safer tests, or qualitative/non‑objective interpretation).
Additional tests designated investigational or not covered over time are identified in policy update notes and the exclusions table. Examples called out include the Mediator Release Test (MRT), which the policy notes lacks peer‑reviewed evidence of clinical outcome benefit; the Pediatric Allergy Solutions (PAS) Macroarray TestAntigen Leukocyte Cellular Antibody (ALCAT) automated food allergy testing; and certain in vitro metal allergy assays for orthopedic implants. The policy records these as investigational or unsupported by sufficient evidence and therefore not covered.
The policy states that repeat skin testing with multiple antigens is not medically necessary when the conditions listed in the covered section for repeat testing are not met. In other words, if a repeat testing indication does not satisfy the policy’s specified pediatric or adult criteria, repeat multi‑antigen skin testing should be considered not medically necessary and may be denied.
Repeat skin testing that includes multiple antigens is explicitly noted as not medically necessary unless the policy’s covered‑section criteria for repeat testing are satisfied. The implementation/update notes reiterate that repeat testing is only appropriate under the described pediatric or adult indications; otherwise the procedure is considered not medically necessary.
Billing, Codes, and Quantity Limits
| 83518 | Applicable service code listed in policy |
| 83519 | Applicable service code listed in policy |
| 86353 | Applicable service code listed in policy |
| 95004 | Allergy testing code (listed) |
| 95017 | Allergy testing code (listed) |
| 95018 | Allergy testing code (listed) |
| 95024 | Allergy testing code (listed) |
| 95027 | Allergy testing code (listed) |
| 95028 | Allergy testing code (listed) |
| 95044 | Allergy testing code (listed) |
| 86001 | Exact code listed in billing/coding section |
| 86003 | Exact code listed in billing/coding section |
| 86005 | Exact code listed in billing/coding section |
| 86343 | Patch test code added to Billing/Coding section |
| 86353 | Code added to Billing/Coding section (per 2011 update) |
| 83516 | Code added to Billing/Coding section (8/27/07) |
| 83518 | Code added to Billing/Coding section (8/27/07) |
| 83519 | Code added to Billing/Coding section (8/27/07) |
| 83520 | Code added to Billing/Coding section (8/27/07) |
| 95017 | Code added to Billing/Coding section (1/1/13 updates) |
Provider Requirements, Documentation, and Denial Triggers
Physician order and possible medical record submission
Coverage is provided only when testing is ordered by a physician and determined to be medically necessary; BCBSNC may request medical records to determine medical necessity and supporting letters alone are insufficient unless they include all specific information needed for determination.
Individual review required for >42 patch tests
Requests for more comprehensive patch testing (greater than 42 patch tests) will be reviewed on an individual basis and require documentation that the policy's two-part clinical criteria are met.
- Policy states: more comprehensive patch testing (>42) may be considered medically necessary when both criteria a) and b) are met (persistent ACD after prior evaluation/treatment OR specified persistent dermatitis features) and dermatitis interferes with activities of daily living.
- Documentation of medical necessity for over 42 tests will be necessary.
Document thorough history and medical necessity for each test
Document a thorough patient history and the medical necessity for each allergy test ordered in the medical record prior to performing testing.
- A thorough history should be taken before allergy tests are ordered and the medical record should document the medical necessity, based on the patient’s history, for each allergy test ordered.
- BCBSNC may request medical records for determination of medical necessity; letters of support alone are not sufficient unless all required information is included.
Support higher-volume testing with medical record justification
Ensure records justify any testing that exceeds routine counts (e.g., inhalant evaluations up to 70 prick tests and up to 40 intradermal tests); be prepared to submit records when requested for medical necessity review.
- Policy notes inhalant evaluation may require up to 70 prick/puncture tests followed by up to 40 intradermal tests.
- BCBSNC may request medical records to determine medical necessity for extensive testing volumes.
Required documentation: history and test-specific necessity
Before ordering allergy tests, document a thorough history and the clinical rationale in the medical record; the record should clearly support medical necessity for each allergen/test.
- A thorough history should be taken before allergy tests are ordered.
- The medical record should document the medical necessity, based on the patient’s history, for each allergy test ordered.
Document medical necessity when patch testing exceeds thresholds
When patch testing exceeds the policy threshold (historically >35, currently >42), include explicit documentation of medical necessity addressing the policy criteria to support approval.
- Greater than 42 patch tests will be reviewed by individual consideration and documentation of medical necessity for over 42 tests will be necessary.
- Prior to the 6/12/12 update the threshold was >35 and documentation was required for over 35 tests; policy history reflects this change.
Denial risk if policy criteria are not met
Testing may 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 if covered-section criteria for repeat testing are not satisfied.
- Policy statement: Allergy testing is not covered when the medical criteria and guidelines shown above are not met.
- Repeat skin testing with multiple antigens is considered not medically necessary when criteria in the covered section are not met.
Provide documentation for excess patch tests or risk denial
If requesting more than the historical patch test thresholds (now >42), include documentation that demonstrates how the case meets the policy’s required clinical criteria; absence of such documentation may result in individual review or denial.
- BCBSNC: documentation of medical necessity for over 42 tests will be necessary.
- Policy lists specific clinical conditions required for >42 testing (persistent ACD after prior evaluation/treatment OR listed persistent dermatitis features AND interference with activities of daily living).
Definitions and Test Descriptions
Background and Clinical Context
Allergic disorders can produce immediate or delayed, localized or systemic reactions to a wide range of agents. In vivo testing—tests performed directly on the patient—includes scratch/prick/puncture (percutaneous) tests, intradermal tests (including serial dilution endpoint titration / SDET/SET/IDT), patch testing for contact allergens, and controlled challenge procedures (e.g., bronchial or food challenges). These in vivo methods are used to identify sensitizations and guide management; in vitro specific IgE blood testing is addressed in a separate Allergen Testing policy.
The policy describes SDET (also called skin endpoint titration or SET) as an intradermal dilutional method that uses incrementally increasing antigen concentrations to determine the endpoint at which a skin reaction becomes positive. SDET may be used diagnostically and, in specific high‑risk situations, to help guide initiation of immunotherapy because it identifies a starting dilution that reduces the risk of adverse reaction.
Revision History and Policy Changes
Specialty Matched Consultant Advisory Panel conducted a review.
Medical Director reviewed the policy following the Specialty Matched Consultant review.
Medical Director completed an additional review in April 2019.
Specialty Matched Consultant Advisory Panel review performed in November 2019.
Medical Director reviewed the policy in November 2019.
Specialty Matched Consultant Advisory Panel conducted an annual review documented in November 2020.
Medical Director reviewed the policy in November 2020.
Specialty Matched Consultant Advisory Panel review recorded in November 2021.
Medical Director completed a policy review in November 2021.
Specialty Matched Consultant Advisory Panel review documented in November 2022.
Medical Director reviewed the policy in November 2022.
Specialty Matched Consultant Advisory Panel conducted a review in November 2023.
Medical Director reviewed the policy in November 2023.
Specialty Matched Consultant Advisory Panel review recorded in November 2024.
Medical Director reviewed the policy in November 2024.
Specialty Matched Consultant Advisory Panel review documented in November 2025.
Medical Director reviewed the policy in November 2025.
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