Allergy Skin and Challenge Testing
Customize your policy alerts
Sign up for all Blue Cross Blue Shield - North Carolina policy alerts
Know when Blue Cross Blue Shield - North Carolina releases new policies or updates existing guidance.
Monitor payer policy activity
Criteria for medical necessity and coverage of in vivo allergy skin tests and challenge procedures (prick, intradermal, patch, bronchial and food challenges) for Blue Cross Blue Shield of North Carolina members; does not address in vitro testing.
No material clinical or coverage changes in this revision.
Coverage Criteria for Allergy Skin and Challenge Testing
Covered testing modalities and conditions
Covered when ALL of the following are met:
See specific modality nodes for additional requirements.
Intradermal testing ordinarily performed when prick/puncture tests are negative.
See expanded patch testing node for criteria when >42 tests are requested.
Used selectively.
Standard randomized/blinded methodology as described.
Covered in specific situations per clinical indication.
Clinical justification and documentation should be provided.
Investigational and not covered
Not covered / investigational tests
Rationale and references for investigational designation provided in policy.
Historic covered items and clarifications
Policy has specified circumstances when testing is covered, limits on number of tests, and when individual review is required. Examples added/edited over time include:
See Implementation/Update history for dates and rationale.
Policy update 4/1/19.
Documented in multiple policy updates (see 6/12/12, 7/1/13, 10/12/09 entries).
See Billing/Coding history entries.
Expanded patch testing criteria
More comprehensive patch testing (greater than 42 patch tests) may be considered medically necessary when ALL of the following are met:
Policy entry effective 7/1/13; documentation of medical necessity required for tests exceeding the threshold.
Criteria for repeat skin testing
Repeat skin testing with multiple antigens is medically necessary in specified scenarios:
Documented in policy update 12/10/13.
Documented in 12/10/13 and 12/30/15 updates.
Specific allergy tests that the policy identifies as investigational are excluded from coverage. The policy lists multiple investigational procedures including the Nasal Challenge Test, Leukocyte Histamine Release Test (LHRT), Rebuck Skin Window Test, Passive Transfer (Prausnitz-Kustner) Test, Cytotoxic Food (Leukocytotoxic) Testing, Provocation Neutralization (Rinkel) Testing, Conjunctival Challenge Testing, Mediator Release Test (MRT), and the Pediatric Allergy Solutions (PAS) Macroarray Test, among others; these procedures are considered investigational because the published peer-reviewed evidence does not establish sufficient diagnostic accuracy or clinical utility to support coverage.
Over the life of this policy BCBSNC has periodically added or clarified tests judged investigational or not covered. Examples from implementation notes include the explicit addition of nasal challenge testing, mediator release testing (MRT), leukocyte histamine release testing, Provocation/Provocation Neutralization (Rinkel) testing, passive transfer tests, Rebuck skin window testing, ALCAT automated food testing and certain in vitro metal allergy assays; these changes are documented in the policy’s update history and rationale statements.
Allergy testing is not covered when the medical criteria and guideline requirements in the covered section are not met. In particular, repeat skin testing using multiple antigens is considered not medically necessary if it does not meet the conditions specified under the covered criteria; documentation of medical necessity will be required for repeat or expanded testing that falls outside the policy’s stated coverage rules.
Repeat skin testing with multiple antigens is considered not medically necessary when the specific conditions in the covered section for repeat testing are not met. The policy notes that greater-than-threshold patch testing (historically >35, later increased to greater than 42 units) will prompt individual review and requires documentation of medical necessity; services exceeding these patch-test limits may be denied if supporting documentation is not provided.
Billing, Codes, and Quantitative Limits
| 86001 | added to Billing/Coding section |
| 86003 | added to Billing/Coding section |
| 86005 | added to Billing/Coding section |
| 86343 | added to Billing/Coding section |
| 86353 | added to Billing/Coding section |
| 83516 | added to Billing/Coding section (8/27/07) |
| 83518 | added to Billing/Coding section (8/27/07) |
| 83519 | added to Billing/Coding section (8/27/07) |
| 83520 | added to Billing/Coding section (8/27/07) |
| 95017 | added to Billing/Coding section (1/1/13) |
Provider Responsibilities and Documentation Requirements
Code listing may require medical-necessity review
This policy lists specific CPT/HCPCS and other procedure codes that may be subject to review for medical necessity; inclusion does not guarantee reimbursement and BCBSNC may request medical records to determine necessity.
Individual review required when tests exceed policy thresholds
Tests that exceed the numeric thresholds noted in the policy (for example, patch testing beyond established limits) are subject to individual review and require documentation of medical necessity.
- Greater than 42 patch tests will be reviewed by individual consideration; documentation of medical necessity for over 42 tests will be necessary.
- Historical entries note greater than 35 patch tests (earlier threshold) also required individual review and documentation.
No step-therapy requirements specified
No step therapy requirements apply to allergy skin and challenge testing under this policy.
- Policy explicitly states Not applicable / no step therapy requirements specified.
No additional provider action
Placeholder — no additional provider-action language beyond the above requirements in the source policy.
Document medical necessity and obtain thorough history
Take a thorough history and document the medical necessity for each allergy test ordered; BCBSNC may request medical records and requires documentation for services exceeding stated limits.
- Medical record must show the clinical justification based on the patient’s history for each test ordered.
- BCBSNC may request records; letters of support/explanation are useful but not sufficient unless they include all specific information needed for medical necessity determination.
Document medical necessity for excess patch testing (>42)
When the number of patch tests exceeds the policy threshold (historically >35 and currently >42), documentation of medical necessity is required and the service will be reviewed by individual consideration.
- 6 weeks avoidance of positive allergens and topical steroid use (if appropriate) should be documented when claiming expanded patch testing.
- Expanded patch testing (>42) requires meeting both clinical persistence criteria and demonstration that dermatitis interferes with activities of daily living.
Denial risk if coverage criteria are unmet
Allergy testing will be denied (not covered) when the medical criteria and guidelines in the covered section are not met; repeat skin testing with multiple antigens is not medically necessary when covered-section criteria are not satisfied.
- Repeat skin testing with multiple antigens is considered not medically necessary if the covered-section criteria are not met.
- Investigational tests listed in the policy are not covered.
Denial trigger: insufficient documentation for excess patch tests
For patch testing that exceeds the policy’s established limits, BCBSNC requires documentation of medical necessity; services above the established patch test maximums will be reviewed individually and may be considered not medically necessary without documentation.
- Greater than 42 patch tests: documentation and meeting the expanded-coverage clinical criteria (persistent ACD after prior evaluation/treatment or specified conditions AND dermatitis interfering with activities of daily living) are required.
- Earlier policy iterations indicated review for >35 patch tests; documentation requirements reflect those historical thresholds as noted in implementation history.
Background
Allergy testing is used to identify offending agents in allergic or hypersensitivity disorders. In vivo testing includes skin procedures such as scratch/prick/puncture (epicutaneous), intradermal tests, patch tests, and controlled food or bronchial challenges; results guide avoidance strategies, pharmacologic treatment, or consideration of immunotherapy. This policy addresses only in vivo testing; in vitro blood-based specific IgE testing is covered under a separate policy.
Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.