NC Medicaid Allergy Testing
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Defines coverage, eligibility, and requirements for in vivo (skin) and in vitro (serologic IgE) allergy testing for NC Medicaid beneficiaries, including EPSDT exceptions for beneficiaries under 21.
Unit limitations for multiple CPT codes were changed (examples: 86003 to 30 units per 365 days; 95004 to 80 units per 365 days; 95017 to 27 units per date of service; 95018 to 19 units per date of service).
Section 3.2.1 wording reorganized to clarify documentation requirements and establish reasonable probability of exposure before ordering tests.
Coverage and Medical Necessity Criteria
General Criteria Covered
Medicaid shall cover allergy testing when medically necessary and when ALL of the following are met:
based on chunk 19
based on chunk 19
based on chunk 19
Medical necessity criteria
Covered when ALL of the following general and specific criteria are met
Source: chunk 19
Source: chunk 20 (Subsection 3.2.1)
Covered Allergy Tests
Once the criteria above are met, the following tests are covered when performed by an appropriate provider or clinical laboratory
Source: chunk 22
Medically Necessary Testing
Covered when ALL of the following are met:
Derived from reorganized Section 3.2.1 and revision notes (chunk 42) and compliance requirements (chunk 36)
Source: Attachment A guidance and compliance requirements (chunks 42, 36)
For beneficiaries under 21, the EPSDT special provision applies. EPSDT requires coverage of medically necessary services that correct or ameliorate a defect, illness, or condition identified through screening, but EPSDT does not require coverage for services that are unsafe, ineffective, experimental or investigational, or not medical in nature or not generally recognized as accepted medical practice.
The following allergy tests are considered investigational and are not covered: leukocyte histamine release; Rebuck skin window; Prausnitz-Kustner test; cytotoxic food testing (leukocytotoxic, Bryans test); conjunctival challenge testing (ophthalmic mucous membrane test); nasal challenge (provocative) test; kinesiology testing; provocation‑neutralization testing; and electrodermal testing.
Policy revision history documents prior updates that added non-covered and investigational tests. Earlier revisions removed and replaced certain CPT listings during code updates and subsequently noted deletion of specific in vitro test listings and addition of other non-covered tests in later revisions.
Services are not covered when the beneficiary does not meet the eligibility requirements in Section 2.0 or when the criteria in Section 3.0 are not met. Coverage also does not apply when the service duplicates another provider's service or when the procedure, product, or service is experimental, investigational, or part of a clinical trial.
Past revisions specifically deleted listings of certain specific IgE in vitro tests and criteria and added additional non-covered tests. Revision notes and Attachment updates document these deletions and subsequent additions to the non‑covered test list.
Provider Responsibilities, Documentation, and Billing
Prior approval requirement for beneficiaries under 21
If a service requires prior approval, providers must still obtain prior approval for beneficiaries under age 21 and consult NCTracks guidance for details on EPSDT and prior approval requirements.
Prior approval not required for allergy testing
Prior approval is not required for allergy testing under this policy; providers may proceed with testing without a prior authorization specific to this policy.
Claim submission and required claim type
Submit claims following NCTracks provider claims and billing guidance and use the appropriate claim type: Professional claims via CMS-1500/837P and Institutional claims via UB-04/837I; institutional claims must follow National Uniform Billing Guidelines unless directed otherwise.
- Report the most specific CPT/HCPCS code that accurately describes the service (see Attachment A: Section C for per-code limits).
- Follow National Coding Guidelines and NCTracks Provider Claims and Billing Assistance Guide.
Conservative therapy requirement — statewide alternatives
Coverage requires that no equally effective, more conservative, or less costly statewide treatment option is available before proceeding with allergy testing.
Conservative empiric therapy must be tried and failed
Providers must document that empiric conservative therapy was tried and failed before allergy testing will be covered.
- Document attempted conservative treatments and evidence of failure in the health record prior to ordering testing.
(Reserved)
Reserved.
EPSDT documentation for beneficiaries under 21
For beneficiaries under 21, provider documentation must demonstrate that the requested allergy testing is medically necessary to correct or ameliorate a defect, illness, or condition to justify any EPSDT exception to policy limitations.
Required clinical documentation to support testing
Providers must document medical and immunologic history and physical exam, establish reasonable probability of exposure, document failure of conservative therapy and all tried/failed allergy treatments, select tests supported by peer-reviewed evidence, and order testing based on these documented findings.
- Complete medical and immunologic history and physical exam.
- Document signs/symptoms suggestive of allergy or a diagnosis indicating allergy (e.g., asthma).
- Establish and document reasonable probability of exposure to the antigen in the beneficiary's environment.
- Record all conservative therapies tried and evidence of failure.
- Select tests with proven efficacy in peer-reviewed literature and order based on documented findings.
Document symptoms and findings that establish reasonable probability of exposure
Document in the health record the beneficiary's symptoms and supporting findings that establish a reasonable probability of exposure to the antigen being tested.
- Record environmental or exposure history that supports testing the specific antigen.
- Ensure documentation links findings (history, exam) to the selected test and antigen.
Verify Medicaid beneficiary eligibility at each service
Verify each Medicaid beneficiary's eligibility at the time of service; failure to verify eligibility may result in claim denial or ineligibility for coverage.
- Confirm enrollment in the NC Medicaid Program and check for service restrictions related to eligibility category.
Denial triggers — eligibility, criteria, investigational services, and insufficient documentation
Claims may be denied if the beneficiary does not meet eligibility in Section 2.0, does not meet the clinical criteria in Section 3.0, the service duplicates another provider's service, the service is investigational, or documentation is insufficient.
- Ensure clinical criteria in Section 3.0 are met and fully documented before billing.
- Avoid duplicate billing for services already rendered by another provider.
Compliance with laws, NCTracks billing guides, and coding/billing rules
Providers must comply with all applicable agreements, federal/state/local laws and regulations, NCTracks billing guides, Medicaid bulletins, fee schedules, NC Medicaid clinical coverage policies, and credentialing/NPI requirements; failure to comply may result in claim denial or recoupment.
- Follow NCTracks Provider Claims and Billing Assistance Guide and Attachment A billing instructions.
- Report the most specific CPT/HCPCS code and adhere to per-code unit limits in Attachment A: Section C.
Codes, Unit Limits, and Billing Constraints
| No codes listed |
| 86003 | Specific IgE testing (each allergen) |
| 86005 | Allergen-specific IgE (per limitations listed) |
| 95004 | Allergen extract testing (per unit rules) |
| 95017 | Skin test, intradermal |
| 95018 | Skin test, percutaneous |
| 95024 | Allergen immunotherapy (per listed CPT) |
| 95027 | Allergen testing (per unit rules) |
| 95028 | Allergen testing (per unit rules) |
| 95044 | Allergen testing (specific IgE in vitro - listed) |
| 95052 | Specific procedure code (listed with unit limit) |
Key Terms and Test Definitions
Clinical Background
Allergy involves IgE‑mediated hypersensitivity reactions to environmental or ingested allergens (for example, pollen, molds, foods, drugs). The purpose of allergy testing—via in vivo (skin) or in vitro (serologic specific IgE) methods—is to identify sensitization to specific antigens to inform management decisions such as avoidance, pharmacologic therapy, or immunotherapy; however, a positive test indicates sensitization and does not by itself confirm clinical allergy.
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