Allergy Testing — Medical Coverage Policy
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Defines medical coverage, necessity, and coding guidance for in vivo and in vitro allergy testing for Blue Cross Blue Shield of Rhode Island members, covering Medicare Advantage and commercial products.
No material clinical or coverage changes in this revision.
Coverage Criteria
Medically necessary testing criteria
Covered when ALL of the following are met
Multiple antigen simultaneous tests are similar to RAST/FAST; ELISA/Act qualitative antibody testing is not established as useful
Not medically necessary / Not covered
Tests considered not covered / not medically necessary
Evidence insufficient to determine impact on health outcomes
Covered Skin Testing
Covered when ALL of the following are met
Skin testing coverage
Covered Specific IgE Testing
Covered when ALL of the following are met
Medicare Advantage and Commercial products have differing ICD-10 diagnosis lists; providers must file the codes with the listed ICD-10 codes
Benefit limitations can differ by employer group or contract. Refer to the member's applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to determine whether a particular test or service is covered, excluded, or subject to different benefit rules.
When submitting in vitro specific IgE testing, providers must follow the coding guidance in the policy. CPTs 86003 and 86008 are considered medically necessary only when filed with the appropriate ICD-10 diagnosis codes listed in the policy attachment for the product (Medicare Advantage or Commercial).
The following CPTs are listed as not covered / not medically necessary and should not be used for routine coverage: 86001, 86005, 86343, and 83516. Filing these codes may result in denial per the policy.
The policy identifies several tests that lack sufficient evidence of clinical utility and are considered not medically necessary or not covered. These include 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 screens, and the ALCAT (Antigen Leukocyte Antibody Test) when used to establish a diagnosis of food allergy.
Rationale provided in the policy notes limited or insufficient diagnostic accuracy data and insufficient evidence that use of these tests improves net health outcomes; therefore, these tests are excluded from coverage or deemed not medically necessary across Medicare Advantage and Commercial products as specified.
Use of certain CPTs is explicitly disallowed for coverage depending on product: CPTs 86001, 86005, 86343 are listed as not covered for Medicare Advantage Plans and not medically necessary for Commercial Products. Additionally, CPT 83516 (commonly used to report ALCAT panels) is not covered for Medicare Advantage Plans and is not medically necessary for Commercial Products when filed with the specified diagnoses.
Providers should avoid billing these CPTs for allergy testing where the policy lists them as not covered/not medically necessary, and should instead use the covered CPTs when appropriate and supported by the documented diagnosis codes.
Coding
| 95004 | Allergen sensitivity testing — example percutaneous/intradermal codes referenced |
| 95017-95052 | Allergy testing codes reported based on number of individual tests performed |
| 95018 | Percutaneous testing example (code referenced in text) |
| 95180 | Rapid desensitization kit (allergy testing integral, not separately reportable) |
| No codes listed |
| 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) |
| 83516 | Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method |
| 86849 | Unlisted immunology procedure |
| 95004 | Scratch/percutaneous allergy test; includes interpretation and report |
| 95017 | Allergy testing any combination of percutaneous and intracutaneous with venoms; include interpretation and report; specify number of tests |
| 95018 | Allergy testing any combination of percutaneous and intracutaneous with drugs or biologicals; include interpretation and report; specify number of tests |
| 95027 | Intracutaneous tests with allergenic extracts for airborne allergens; includes interpretation and report |
| 95024 | Inject suspected allergenic substances into the skin (intradermal/intracutaneous); includes interpretation and report |
| 95028 | Intracutaneous (intradermal) tests with allergenic extracts, delayed type reaction, including reading |
| 95052 | Photo patch test(s) (specify number of tests) |
Provider Actions and Requirements
Prior Authorization
No prior authorization is applicable per this policy.
Diagnosis-linked requirement for specific IgE testing
The following CPT codes are considered medically necessary when filed with the diagnosis codes listed in the referenced attachment: 86003 and 86008. Providers must file these tests with diagnosis codes linked to the clinical indication per the attachment; testing is considered medically necessary only when the diagnosis linkage and clinical documentation support the test.
Step Therapy
Not applicable — there are no step therapy requirements specified in this policy.
Sequential Testing
Intracutaneous (intradermal) allergy tests should only be performed following negative scratch, puncture, or prick (percutaneous) tests, consistent with sequential testing requirements.
Required Documentation and Audit Risk
Medical necessity documentation must include patient history, physical examination and previous laboratory findings; current treatment plan; prescribed medications; and a risk assessment plan. Blue Cross Blue Shield of Rhode Island reserves the right to audit services; all documentation must be available upon request. Failure to produce requested medical record documentation may result in denial or retraction of payment.
- Minimum documentation: patient history, physical exam, prior lab findings
- Current treatment plan and prescribed medications
- Risk assessment plan
- BCBSRI may audit services; failure to provide records may result in denial or retraction of payment
Not Covered / Not Medically Necessary Codes
The following CPT codes are not covered for Medicare Advantage Plans and are not medically necessary for Commercial Products: 86001, 86005, 86343, and 83516.
- 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)
- 83516 — Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method
Background
Allergic disorders may produce immediate (IgE-mediated) or delayed reactions and can affect multiple organ systems. Diagnostic evaluation uses a combination of clinical history and examination to determine the most appropriate testing approach.
Available diagnostic approaches include in vivo testing (skin tests: percutaneous/scratch/puncture/prick, intradermal, and patch testing) and in vitro serum assays for allergen-specific IgE (e.g., RAST, ELISA). The choice of test is driven by the patient's history and physical exam; some tests are used when skin testing is not possible or contraindicated, while others (such as ELISA/Act qualitative antibody testing, LHRT, LMRA, and ALCAT) are not supported by sufficient evidence and are considered not clinically useful for establishing allergy diagnoses.
Definitions
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