CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Allergy testing (in vivo and in vitro) and select laboratory assays

This policy describes coverage and medical necessity guidance for allergy testing methods (skin/in vivo and serum/in vitro), and outlines tests considered not medically necessary for Blue Cross Blue Shield of Rhode Island members under Medicare Advantage and Commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyAllergy testing (in vivo and in vitro) and select laboratory assays

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionWhen billing covered skin test CPT codes include number of tests/units and provider interpretation/report; annual maximum units apply.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Covered CPT codes

5Not covered tests

3 yrsRetesting interval

8095004 max units/yr

2795017 max units/yr

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage and Medical Necessity Criteria

Medical necessity for allergy testing (in vivo and in vitro)

Covered when ALL of the following are met

General clinical necessity for allergy testing: Testing (in vivo or in vitro) must be chosen based on the patient's clinical presentation and clinician's judgment and be specific to the patient's history and physical examination findings.

Chunks 6,7

Number and type of tests: Number and type of antigens used must be judicious and related to history, physical findings and clinical judgment; not all patients receive the same series or number of tests.

Chunk 7

Retesting frequency: Retesting with the same antigens should rarely be necessary within a three-year period; routine annual repetition is not indicated.3 years

Chunk 7

Indications for intradermal testing: Intradermal (intracutaneous) testing is medically necessary when selected based on clinical presentation and clinician judgment to increase sensitivity (for example when percutaneous tests are negative and strong suspicion remains), and when used for IgE-mediated reactions to inhalants, hymenoptera (stinging insects), specified drugs (e.g., penicillins, macromolecular agents) or vaccines.

Chunks 6 and 11

Covered laboratory serum IgE tests

Covered CPT codes when filed with a covered diagnosis

Covered CPT codes: CPT codes 86003 and 86008 (allergen specific IgE quantitative or semiquantitative, crude extract and recombinant/purified component, respectively) are considered medically necessary when filed with covered diagnosis codes as listed in the policy attachments.

Chunks 3,18

Tests considered experimental or not medically necessary

Not medically necessary / not covered

Specific tests considered not medically necessary: The following tests are considered not covered / not medically necessary due to insufficient evidence of clinical utility: ELISA/Act qualitative antibody testing; LMRA (Lymphocyte Mitogen Response Assays) by ELISA/Act; Leukocyte Histamine Release Test (LHRT); IgG ELISA, indirect method; qualitative multi-allergen screen. The Antigen Leukocyte Antibody Test (ALCAT) is not covered/not medically necessary when performed to establish a diagnosis of food allergy.

Chunks 4,5,14-17

Covered tests and limits

Covered when billed with appropriate diagnosis codes and within annual unit limits

General coverage conditions: Specific IgE quantitative tests (CPT 86003, 86008) are medically necessary when filed with the diagnosis codes listed in the policy attachments (separate lists for Medicare Advantage and Commercial).

See ICD-10 attachments referenced in document.

Skin testing coverage and limits: Skin test CPT codes (95004, 95017, 95018, 95024, 95027, 95028, 95052) are covered but subject to specified annual maximum allowed units per calendar year and must include the number of tests performed and provider interpretation/report as part of the code.95004=80;95017=27;95018=19;95024+95028=40 total;95027=90;95052=36

Intracutaneous tests should follow negative scratch/puncture/prick tests.

Benefits may vary between groups and contracts. Refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to determine applicable not medically necessary or not covered benefits for that contract.

The following CPT codes are not covered / not medically necessary for Medicare Advantage Plans and are not medically necessary for Commercial Products: 86001 (Allergen specific IgG quantitative or semiquantitative, each allergen), 86005 (Allergen specific IgE; qualitative, multiallergen screen), and 86343 (Leukocyte histamine release test). In addition, CPT 83516 (immunoassay; used for ALCAT panels) is not covered / not medically necessary when filed with the specified ICD-10 diagnosis codes K52.21–K52.29.

The Antigen Leukocyte Antibody Test (ALCAT) and several related in vitro assays are considered not covered / not medically necessary because the evidence is insufficient to demonstrate clinical utility. Specifically, ALCAT is not covered when performed to establish a diagnosis of food allergy. Other assays considered not medically necessary include ELISA/Act qualitative antibody testing, LMRA (Lymphocyte Mitogen Response Assays) by ELISA/Act, Leukocyte Histamine Release Test (LHRT), IgG ELISA indirect method, and qualitative multi-allergen screens.

Tests that specifically should not be billed for coverage include IgG testing (CPT 86001), qualitative multiallergen IgE screens (CPT 86005), and leukocyte histamine release tests (CPT 86343), as these are listed as not covered/not medically necessary. ALCAT-related testing commonly reported with CPT 83516 is also not covered/not medically necessary when submitted with the designated ICD-10 codes (K52.21–K52.29).

CPT and Coding Guidance

Covered CPT CodesCPTCovered

86003	Allergen specific IgE; quantitative or semiquantitative, crude allergen extract, each
86008	Allergen specific IgE; quantitative or semiquantitative, recombinant or purified component, each

Not covered / Not medically necessary testsmixedNot Covered

ALCAT	Antigen Leukocyte Antibody Test (proprietary panel names vary)
LHRT	Leukocyte Histamine Release Test
ELISA/Act	ELISA/Act qualitative antibody testing
LMRA	Lymphocyte Mitogen Response Assays by ELISA/Act
IgG ELISA, indirect	IgG ELISA, indirect method
Qualitative multi-allergen screen	Qualitative multi-allergen screen

Covered CPT Codes (Medicare Advantage / Commercial)CPTCovered

86003	Allergen specific IgE; quantitative or semiquantitative, crude allergen extract, each
86008	Allergen specific IgE; quantitative or semiquantitative, recombinant or purified component, each

Not Covered / Not Medically Necessary CPT CodesCPTNot Covered

86001	Allergen specific IgG quantitative or semiquantitative, each allergen
86005	Allergen specific IgE; qualitative, multiallergen screen (eg, disk, sponge, card)
86343	Leukocyte histamine release test (LHR)

Unlisted immunology codeCPT

86849

Unlisted immunology procedure

Covered Skin Test CPT Codes with annual limitsCPTCovered

95004	Scratch, puncture, or prick test; includes interpretation and report
95017	Combination percutaneous and intracutaneous testing with venoms; specify number of tests
95018	Combination percutaneous and intracutaneous testing with drugs or biologicals; specify number of tests
95027	Intracutaneous tests with allergenic extracts for airborne allergens; specify number of tests
95024	Intracutaneous tests (injection) to determine specific allergies; includes interpretation and report
95028	Intracutaneous (intradermal) tests with allergenic extracts, delayed type reaction; specify number of tests
95052	Photo patch test(s); specify number of tests

ALCAT leukocyte size change — key threshold

Threshold for response10% increase in leukocyte size is considered characteristic of a response on ALCAT testing

PurposeIntended to identify foods and environmental agents associated with intolerance by measuring leukocyte size and count changes after exposure

MethodologyBaseline leukocyte size/number measured, blood incubated with multiple agents, post‑exposure cell size/count compared using Coulter technique

95004 Annual Maximum Allowed Units

CPT code95004 - Scratch, puncture, or prick test (includes interpretation and report)

Annual maximum allowed units80 units per calendar year

Units explanationA total of 80 scratch/puncture/prick allergy tests are eligible for reimbursement per calendar year

95017 Annual Maximum Allowed Units

CPT code95017 - Combination percutaneous and intracutaneous testing with venoms (specify number of tests)

Annual maximum allowed units27 units per calendar year

Units explanationA total of 27 tests filed under 95017 are eligible for reimbursement per calendar year

95018 Annual Maximum Allowed Units

CPT code95018 - Combination percutaneous and intracutaneous testing with drugs or biologicals (specify number of tests)

Annual maximum allowed units19 units per calendar year

Units explanationA total of 19 tests filed under 95018 are eligible for reimbursement per calendar year

95024 / 95028 Combined Annual Maximum Allowed Units

CPT codes95024 and 95028 - Intracutaneous/intradermal allergy testing (specify number of tests)

Combined annual maximum allowed units40 units total per calendar year (combined limit for 95024 + 95028)

Example allocationExample: 40 units for 95024, or 20 units for 95024 and 20 units for 95028

95052 Annual Maximum Allowed Units

CPT code95052 - Photo patch test(s) (specify number of tests)

Annual maximum allowed units36 units per calendar year

Units explanationA total of 36 photo patch tests are eligible for reimbursement per calendar year

Provider Requirements and Billing Actions

Prior Authorization

Prior authorization is not applicable for the tests described in this policy.

Billing Rule

Annual Unit Limits for Skin Testing

Coverage for listed skin testing CPT codes is limited by annual maximum allowed units per calendar year. When billing covered skin test CPT codes (95004, 95017, 95018, 95024, 95027, 95028, 95052), include the number of tests/units on the claim and ensure documentation supports the number of tests performed. Positive or negative control tests should not be included in the units reported. Documentation must demonstrate medical necessity based on patient-specific history, physical exam, prior laboratory findings, current treatment plan and prescribed medications. Blue Cross Blue Shield of Rhode Island may audit records; failure to produce requested documentation may result in denial or retraction of payment.

95004 — Scratch/puncture/prick tests: Annual maximum allowed units = 80.
95017 — Combination percutaneous and intracutaneous with venoms: Annual maximum allowed units = 27.
95018 — Combination percutaneous and intracutaneous with drugs/biologicals: Annual maximum allowed units = 19.
95024 — Intracutaneous (intradermal) injections: Annual maximum allowed units = 40 (40 units is the maximum allowed for codes 95024 and 95028 combined).
95027 — Intracutaneous tests for airborne allergens: Annual maximum allowed units = 90.
95028 — Intracutaneous (intradermal) delayed type tests: Annual maximum allowed units = 40 (40 units is the maximum allowed for codes 95024 and 95028 combined).
95052 — Photo patch tests: Annual maximum allowed units = 36.
Units explanation examples: Controls (positive/negative) are not counted. Where codes share a combined maximum (95024 and 95028), the combined total cannot exceed the stated maximum (e.g., 40 units total across the two codes).

Step Therapy

Not applicable; testing selection should be based on clinical presentation and clinician judgment rather than a mandated step sequence.

Documentation Required

Required Medical Record Elements

Medical Necessity Guidance requires documentation of patient history, physical exam and previous laboratory findings; current treatment plan; prescribed medication(s); and a risk assessment plan. Maintain all supporting documentation in the medical record and make available upon BCBSRI request.

Documentation Required

Required Documentation for Skin Testing

When billing covered skin test CPT codes (95004, 95017, 95018, 95024, 95027, 95028, 95052), include the number of tests/units and provide documentation to justify the number of tests performed. Failure to produce requested documentation upon audit may result in denial or retraction of payment.

Denial Risk

Documentation Audit Risk

Failure to produce requested documentation upon audit may result in denial or retraction of payment.

Denial Risk

Non-covered Test Codes

Claims for CPT codes 86001, 86005, 86343 and CPT 83516 (when filed with ICD-10 K52.21-K52.29) are not covered / not medically necessary as specified in the policy.

86001 — Allergen specific IgG quantitative or semiquantitative, each allergen (not covered).
86005 — Allergen specific IgE; qualitative, multiallergen screen (not covered).
86343 — Leukocyte histamine release test (LHR) (not covered).
83516 — Immunoassay (multiple step) not covered when filed with ICD-10 K52.21-K52.29.

Note

Order of Skin Testing

Intracutaneous (intradermal) allergy tests should only follow negative scratch, puncture, or prick tests.

Background and Scope

Allergy testing encompasses both in vivo (skin) and in vitro (serum) methods to identify immunologic sensitivity. In vivo methods include percutaneous (scratch/ puncture/prick), intradermal, and patch testing; these require clinical correlation and appropriate supervision. In vitro testing measures specific or total serum IgE (e.g., RAST, ELISA) and should be ordered based on the patient's history and physical exam findings and in conjunction with clinician judgment.

Selection of the number and type of antigens must be judicious and directly related to the patient's clinical history and examination. Retesting with the same antigens should rarely be necessary within a three-year period, and routine annual repetition is not indicated. Intradermal (intradermal) testing is medically necessary only when chosen for increased sensitivity—typically after negative percutaneous testing when clinical suspicion remains—or for suspected IgE-mediated reactions to inhalants, hymenoptera venoms, specific drugs, or vaccines.

Definitions

Percutaneous testing — definition and key points

Percutaneous testing definitionScratch, puncture, or prick skin test used to evaluate IgE‑mediated hypersensitivity; requires medical supervision due to a small risk of anaphylaxis

Clinical usePreferred test for immediate hypersensitivity to inhalants, foods, hymenoptera and certain drugs/vaccines

Safety noteRequires medical supervision because of small but significant risk of anaphylaxis

Intradermal testing — definition and indications

Intradermal testing definitionInjection of small amounts of antigen into the superficial layers of the skin; used when increased sensitivity is required (e.g., after negative percutaneous tests)

Typical programMay include two concentrations of an extract (weaker and stronger); three or more concentrations of one extract generally not medically necessary

IndicationsMedically necessary for IgE‑mediated reactions to inhalants, hymenoptera, specific drugs (penicillins, macromolecular agents) or vaccines

Patch testing — definition and indications

Patch testing definitionGold standard for identifying allergic contact dermatitis; indicated for suspected contact allergens causing dermatitis

Clinical indicationsEvaluate nonspecific dermatitis or pruritus to differentiate allergic contact dermatitis (ACD) from irritant contact dermatitis (ICD)

Use caseReserved for patients with skin eruptions where a contact allergy source is likely

ALCAT — purpose and limitations

ALCAT definitionAntigen Leukocyte Antibody Test intended to identify foods and environmental agents for which an individual may have intolerance by measuring changes in leukocyte size/count after exposure

Not for diagnosing food allergyALCAT is not intended to diagnose food allergy; it is used to identify intolerances to guide elimination diets

Test panels and scopeCommercial ALCAT panels list multiple panels with total agents tested ranging from 81 to 370

LHRT — definition and coverage stance

LHRT definitionLeukocyte Histamine Release Test measures in vitro histamine release from basophils after allergen exposure as a correlate to in vivo response

Method summaryAllergen added to peripheral blood leukocytes and histamine release from basophils is measured; newer automated methods exist but diagnostic accuracy is insufficient

Coverage stanceEvidence is insufficient for diagnostic accuracy; LHRT is considered not medically necessary

86003 / 86008 — serum specific IgE tests

86003 definitionAllergen specific IgE; quantitative or semiquantitative, crude allergen extract, each

86008 definitionAllergen specific IgE; quantitative or semiquantitative, recombinant or purified component, each

Coverage noteBoth codes are considered medically necessary when filed with covered diagnosis codes as listed in the policy attachments

86001, 86005, 86343 — non‑covered tests

86001Allergen specific IgG quantitative or semiquantitative, each allergen — listed as not covered/not medically necessary

86005Allergen specific IgE; qualitative, multiallergen screen (eg, disk, sponge, card) — listed as not covered/not medically necessary

86343Leukocyte histamine release test (LHR) — listed as not covered/not medically necessary

83516 (ALCAT) — coding and coverage note

83516 (ALCAT)Immunoassay code commonly used for ALCAT panels; not covered/not medically necessary when filed with ICD‑10 K52.21‑K52.29

Notes on reportingVarious sizes of ALCAT panels are likely reported with multiple units of CPT code 83516

Related exclusionClaims with CPT 83516 and specified ICD‑10 diagnoses (K52.21‑K52.29) are identified as not covered/not medically necessary