CurrentCapital BluecrossPolicy MP 2.001

Allergy Testing and Immunotherapy

Defines medical necessity, limits, and investigational status for allergy testing methods and immunotherapy services provided to Capital BlueCross members and describes program variations (e.g., CHIP). Affects providers ordering or performing allergy diagnostic tests and immunotherapy.

Policy Summary

PayerCapital Bluecross

PolicyAllergy Testing and Immunotherapy

Policy CodePolicy MP 2.001

Change TypeAdministrative / coding updates (no material clinical changes)

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionVerify coding and prior authorization requirements for specific tests and document medical necessity and correlation of testing to the patient’s history before submission.

SourceLink

70Percutaneous QLL

40Intracutaneous QLL

80Endpoint QLL

6-12 moMaintenance re-eval interval

1 yearMaintenance continuation limit

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.

Covered procedure groups

Coverage Criteria for Allergy Testing and Immunotherapy

inv-01: Allergy Testing — General Medical Necessity

Specific allergy testing may be considered medically necessary when ALL of the following are met:

Allergy testing general necessity: Symptoms are not adequately controlled by empiric conservative therapy; Testing must correlate specifically to the individual's history, risk of exposure and physical findings; Test technique and/or allergens tested must have proven efficacy demonstrated through scientifically valid studies published in the peer-reviewed literature.

From policy statement

inv-02: Covered Allergy Test Types

The following allergy testing techniques may be considered medically necessary when general criteria are met:

Covered testing modalities: Direct skin tests (percutaneous [scratch/prick/puncture] and intracutaneous/intradermal) for diagnosis/evaluation/treatment when signs/symptoms or diagnosis of allergy are present; Patch test and Photo patch test for contact/photoallergic dermatitis; Bronchial challenge tests (e.g., histamine, methacholine) for airway hyperresponsiveness; Double-blind food challenge testing; Serial Endpoint Testing (SET/SDET/IDT) when used with immunotherapy to determine safe starting doses; Specific IgE in vitro tests (RAST, MAST, FAST, ELISA) for inhalants, foods, insect stings and certain drugs (or when skin testing is not feasible); Total serum IgE concentration for select diagnoses (e.g., allergic bronchopulmonary aspergillosis, immune deficiencies with elevated IgE, IgE myeloma/pemphigoid).QLL limits apply: <=70 percutaneous or <=40 intracutaneous tests; <=80 endpoint tests per benefit period

Includes limits and indications for in vitro testing (children <=5, extensive dermatitis, marked dermatographism, pervasive developmental disorder/intellectual disability)

inv-03: Repeat Allergy Skin Testing

Repeat skin testing may be considered medically necessary in these situations:

Repeat testing indications: Children initially sensitive to foods or indoor environmental exposures who later develop pollen/outdoor mold sensitivities; Adults with prior food allergy who require reevaluation to assess for resolution; Adults after three to five years of venom immunotherapy who require reassessment for resolution of venom allergy; Adults who develop increased atopic symptoms suggesting new sensitizations.

From Repeat Allergy Skin Testing section

inv-04: Allergy Immunotherapy — Initial and Maintenance

Allergy immunotherapy may be considered medically necessary when ALL of the following are met:

Immunotherapy necessity: There is demonstrated hypersensitivity that cannot be adequately managed by medication, avoidance, or environmental control measures; Allergen extracts (airborne or insect venom) are prepared individually for the member; During maintenance, the individual is re-evaluated every 6 to 12 months to determine efficacy, need for dosing or content adjustments, ensure compliance, and monitor for local and systemic adverse reactions; Continuation beyond one year of maintenance requires documentation of benefit (noticeable symptom decrease, increased tolerance, reduced medication use) or a reasonable explanation for lack of improvement and why discontinuation would worsen allergies.

Maintenance continuation requires documented benefit after one year or rationale for continued therapy

inv-05: Investigational / Not Covered Tests

Tests and procedures categorized by policy as Investigational (not covered) when used for diagnosis of food or other allergies due to insufficient evidence include:

Investigational tests (not covered): Provocative tests for food or food additive allergies (intracutaneous, subcutaneous, sublingual); Nasal challenge/provocation tests; Conjunctival (ophthalmic) challenge tests; IgG ELISA/IgG (including IgG4) serologic testing for foods; Mediator Release Testing (MRT) including LEAP-related testing; Complement antigen testing; Food Immune Complex Assays (FICA); Leukocyte/histamine release assays and other non-standardized serologic or cell-based assays; Provocative and neutralization therapy for food allergies; At-home administration and preparation of immunotherapy (listed among investigational or not covered practices).

Considered investigational due to lack of validated utility, low-quality evidence, potential for false positives/negatives and harm from inappropriate dietary restrictions or delayed appropriate workup

inv-06: Home Immunotherapy / Administration Requirements

Home allergy immunotherapy considerations:

Home Allergy Immunotherapy stance: Home allergy immunotherapy (self-administration and at-home preparation of serum) is considered investigational in general; guideline-based recommendation is that allergen immunotherapy be administered in a medical facility with trained staff and equipment to recognize and treat anaphylaxis. Under rare circumstances (e.g., venom immunotherapy for remote patients) at-home administration may be considered when the benefit clearly outweighs the risk and appropriate safeguards/documentation are in place.

Observational studies report low major reaction rates in selected cohorts but generalizability is limited; verify documentation of adherence to accepted safety protocols if home immunotherapy is used

Product variations and branded/novel test panels that lack validation are listed as investigational and are excluded from coverage. Examples specifically named in the policy include ALCAT/automated food allergy testing, cytotoxic (Bryan's) food testing, leukocyte histamine release test (LHRT), provocative tests for food or additives (e.g., Rinkel method), and other non‑standard methods used to diagnose food allergy.

The policy also designates other non‑standard serologic and cell‑based assays and neutralization/provocative therapies (including at‑home immunotherapy preparation and administration) as investigational and therefore not covered unless otherwise supported by member benefit terms.

The policy explicitly discourages use of food‑specific IgG assays and IgG subclass/IgG4 testing for diagnosis of food allergy or intolerance, stating they are considered investigational and should not be used in diagnostic evaluation because IgG/IgG4 responses reflect physiologic exposure rather than pathologic sensitization.

Additionally, Mediator Release Testing (MRT) including the LEAP program, complement antigen testing, Food Immune Complex Assays (FICA), and similar non‑standardized assays are categorized as investigational due to insufficient evidence of diagnostic utility and risk of false positives or negatives that may lead to inappropriate dietary restrictions or delayed appropriate workup.

The policy history documents coding maintenance activity and administrative updates; it also records that codes 86807 and 86808 were removed because they were not applicable and should no longer be used for billing under this policy.

Providers should confirm current coding in claims submissions and avoid use of these removed/obsolete codes to reduce risk of improper billing or denial.

Quantity level limits (QLL) apply per benefit period and are enforced as not medically necessary when exceeded. Specifically, a cumulative total of more than 70 percutaneous tests or more than 40 intracutaneous (intradermal) tests will be considered not medically necessary.

For serial endpoint testing used with immunotherapy (SET/SDET/IDT), a cumulative total exceeding 80 endpoints per benefit period will be considered not medically necessary.

Continuation of allergy immunotherapy beyond the initial maintenance period requires documented clinical benefit. The policy considers immunotherapy not medically necessary after one year in maintenance unless there is documentation of one or more of the following: a noticeable decrease in symptoms, increased tolerance to the offending allergen, reduced medication usage, or a reasonable explanation for lack of improvement and why discontinuation would likely worsen the condition.

During maintenance, individuals must be re‑evaluated every 6–12 months to assess efficacy, dosing adjustments, compliance, and to monitor for local and systemic adverse reactions; continued therapy should be supported by those re‑evaluation findings.

The policy states unequivocally that food‑specific IgG, IgG subclasses, and IgG4 testing should not be used for diagnostic evaluation of food allergy or intolerance because these assays measure physiologic immune responses to exposure rather than evidence of pathologic allergy.

As a result, these tests are considered irrelevant for diagnostic workup of food‑related complaints and are categorized as investigational / not medically necessary for that purpose.

Coding and Quantity Limits

Investigational and therefore not coveredCPTNot Covered

95065	Procedure Code listed under Investigational and therefore not covered
83516	Procedure Code entry appears in investigational list
86001	Procedure Code entry appears in investigational list
86160	Procedure Code entry appears in investigational list
86332	Procedure Code entry appears in investigational list
86343	Procedure Code entry appears in investigational list
86849	Procedure Code entry appears in investigational list
95060	Procedure Code entry appears in investigational list

Investigational and therefore not covered (repeat)CPTNot Covered

95065	Procedure Code listed under Investigational and therefore not covered
83516	Procedure Code entry appears in investigational list
86001	Procedure Code entry appears in investigational list
86160	Procedure Code entry appears in investigational list
86332	Procedure Code entry appears in investigational list
86343	Procedure Code entry appears in investigational list
86849	Procedure Code entry appears in investigational list
95060	Procedure Code entry appears in investigational list

Covered when Medically NecessaryCPTCovered

95018	Listed under Covered when Medically Necessary (paired with other codes in mapping)
95024	Mapped in covered group
95027	Mapped in covered group
95028	Mapped in covered group
95044	Mapped in covered group
95052	Mapped in covered group
95056	Mapped in covered group
95070	Mapped in covered group
95076	Listed under Covered when Medically Necessary
95132	Listed under Covered when Medically Necessary

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ICD-10-CM Diagnosis Codes (selection)ICD-10

B44.81	Allergic bronchopulmonary aspergillosis
D82.0	Wiskott-Aldrich syndrome
D82.4	Hyperimmunoglobulin E [IgE] syndrome
H65.411	Chronic allergic otitis media, right
J30.1	Allergic rhinitis due to pollen
J45.20	Mild intermittent asthma, uncomplicated
L20.0	Besnier's prurigo
L50.0	Allergic urticaria
R05	Cough
R06.00	Dyspnea, unspecified

Relevant ICD-10 Diagnosis CodesICD-10

J45.991	Cough variant asthma
J45.998	Other asthma
L20.0	Besnier's prurigo
L20.81	Atopic neurodermatitis
L20.82	Flexural eczema
L20.84	Intrinsic (allergic) eczema
L20.89	Other atopic dermatitis
L24.A0	Irritant contact dermatitis due to friction or contact with body fluids, unspecified
L24.A9	Irritant contact dermatitis due friction or contact with other specified body fluids
L29.9	Pruritus, unspecified

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Procedure / Proprietary Codes mentioned in historyCPT | HCPCS | mixed

0165U	New/added code referenced in policy history
0178U	New/added code referenced in policy history
95071	Deleted code referenced in policy history
86807	Removed code referenced in policy history
86808	Removed code referenced in policy history

Percutaneous and Intracutaneous Test Limits

Percutaneous test limit (per benefit period)Maximum cumulative total of 70 percutaneous (scratch/prick/puncture) tests per benefit period

Intracutaneous (intradermal) test limit (per benefit period)Maximum cumulative total of 40 intracutaneous tests per benefit period

Not medically necessary thresholdQuantity level limits greater than 70 percutaneous or 40 intracutaneous tests will be considered not medically necessary per benefit period

Endpoint (SET/SDET/IDT) Test Limit

Endpoint tests cumulative limit (per benefit period)Maximum cumulative total of 80 endpoint tests (SET, SDET, IDT) per benefit period

Provider Responsibilities and Billing Considerations

Note

Program-specific requirements

Program variations: CHIP (Capital Cares 4Kids) — quantity level limits (QLL) do not apply. Verify member program (CHIP vs commercial) before applying QLL-based denials.

CHIP (Capital Cares 4Kids): QLL do not apply

Prior Authorization

Prior authorization / medical necessity

Prior authorization / medical necessity: Services are covered only when medically necessary and supported by documentation that testing or immunotherapy is aligned to the individual’s history, exposure risk, physical findings, and response to prior conservative therapy. Identification of a code in the coding section does not guarantee coverage — final payment is contingent on member benefits and eligibility.

Coverage contingent on medical necessity and member benefit terms; verify eligibility at time of service
Testing and immunotherapy must correlate to history, exposure risk, and physical findings and be necessary after conservative therapy

Background

Allergic disorders can present with systemic or localized manifestations across organ systems and are evaluated with both in vivo and in vitro methods. Common in vivo evaluations include skin prick (percutaneous) and intracutaneous (intradermal) testing, patch and photo patch tests, bronchial challenge testing, and controlled food challenges.

In vitro testing such as specific IgE assays (RAST, MAST, FAST, ELISA) complement in vivo methods and are useful when skin testing is contraindicated (e.g., extensive dermatitis, marked dermatographism, young children). Serial endpoint testing (SET/IDT) is an intradermal method that can guide initiation and dosing of immunotherapy.

Definitions

Serial Endpoint Testing (SET / IDT) — definition

DefinitionSerial Endpoint Testing (SET/IDT) is a form of intradermal skin testing using increasing antigen doses to determine the concentration at which the reaction changes from negative to positive (the endpoint)

Clinical useUsed for diagnosis of allergic disorders and to guide initiation of immunotherapy by using the endpoint dilution as the starting antigen dose

SynonymsAlso referred to as serial endpoint titration or intradermal dilutional testing (IDT)

Mediator Release Testing (MRT) / LEAP — definition

DefinitionMediator Release Testing (MRT) attempts to measure release of chemical mediators from white blood cells and platelets in response to specific foods, chemicals, or additives; often used with the LEAP program to identify delayed food reactions

Clinical stance

Revision History and Policy Updates

2025-07-21Consensus ReviewLatest

Formatting changes to the policy statement and updates to background and references; no change to intent.

2024-05-30Consensus Review

Policy statement unchanged; references updated.

2024-01-18Administrative Update

Policy Summary

PayerCapital Bluecross

PolicyAllergy Testing and Immunotherapy

Policy CodePolicy MP 2.001

Change TypeAdministrative / coding updates (no material clinical changes)

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionVerify coding and prior authorization requirements for specific tests and document medical necessity and correlation of testing to the patient’s history before submission.

SourceLink

On This Page

Not medically necessary thresholdQuantity level limits greater than 80 endpoint tests will be considered not medically necessary per benefit period

Use with immunotherapySerial endpoint testing (SET) when used in conjunction with immunotherapy to determine a safe starting dose is subject to the endpoint test limit

Policy updates count

Policy updates timeframeMultiple administrative updates and consensus reviews documented between 2020 and 2025

Notable code changesNew proprietary/procedure codes added in 2020-2024 (e.g., 0165U, 0178U); deleted/removed codes noted (e.g., 95071 removed, 86807 and 86808 removed)

Review actionsConsensus reviews and administrative updates recorded for coding, references, and formatting (2020–2025) without change to policy intent

Denial Risk

Quantity level limits (QLL) greater than

Quantity level limits (QLL) and denial thresholds: Enforce cumulative-per-benefit-period QLLs for percutaneous/intracutaneous tests and endpoint tests; exceedance will be considered not medically necessary except for CHIP members.

Percutaneous/intracutaneous tests: cumulative total >70 percutaneous or >40 intracutaneous tests = not medically necessary per benefit period
Endpoint tests (SET/SDET/IDT): cumulative total >80 endpoints = not medically necessary per benefit period
CHIP members: QLL do not apply

Documentation Required

During maintenance immunotherapy, individuals must be re-evaluated

Allergy immunotherapy limitations and continuation: Maintenance immunotherapy requires re-evaluation every 6–12 months to document efficacy, dosing adjustments, compliance, and adverse event monitoring. Immunotherapy in the maintenance phase is considered not medically necessary after one year without documentation of benefit (symptom decrease, increased tolerance, medication reduction, or reasonable explanation for lack of improvement).

Re-evaluate every 6 to 12 months during maintenance: efficacy, dosing, compliance, adverse reactions
Discontinue (not medically necessary) after 1 year in maintenance without documented benefit

Documentation Required

Home immunotherapy safety documentation

Home immunotherapy: Home administration and at‑home preparation of allergy immunotherapy are considered investigational and not covered. If home immunotherapy is offered in extraordinary circumstances, document safety protocols and surveillance measures (training, emergency plan, dosing verification, adherence monitoring) — however, standard policy treats home administration as investigational.

At-home administration and home preparation of serum: investigational / not covered
If claimed, include detailed safety documentation: patient training, emergency action plan, adherence/surveillance procedures (documentation subject to denial risk)

Denial Risk

Investigational procedure codes not covered; coding-related denial risk

Investigational procedures and coding-related denial risk: Procedures identified as investigational in the coding section are not covered and should trigger denial. Use of removed, obsolete, or investigational procedure codes (example: legacy or deleted codes noted in policy history) may result in denial or claim processing issues.

Investigational / not covered codes listed in Investigational section — deny if billed
Use current, active CPT/HCPCS codes; use of removed/obsolete codes may trigger denial (e.g., previously deleted codes noted in policy history)
Identification of a code in coding section ≠ automatic coverage; confirm medical necessity and benefits

Billing Rule

Use of encounter and allergy status codes

Use encounter and allergy status codes to document testing encounters and allergy status. Include appropriate ICD-10 Z-codes for encounter for allergy testing and Z88/Z91 family codes for allergy/drug/food status where applicable to support medical necessity and claims adjudication.

Z01.82 — Encounter for allergy testing
Z88.x / Z91.x — Allergy status codes (penicillin, other antibiotics, food, insect, latex, radiographic dye, etc.)
Use encounter and allergy status codes on claim and in provider notes to document reason for testing or immunotherapy

Note

Allergy testing is considered medically necessary when

Allergy testing medical necessity: Allergy testing (skin tests, specific IgE in vitro tests, total serum IgE for specific diagnoses, bronchial challenge, patch/photo patch, double blind food challenge, serial endpoint testing when appropriate) is considered medically necessary when criteria are met: symptoms not controlled by conservative therapy; testing correlates to history/exposure/physical findings; and test technique/allergens have demonstrated efficacy in peer-reviewed literature.

Direct skin tests (percutaneous/intracutaneous) — subject to QLLs unless CHIP
Specific IgE in vitro tests (RAST/MAST/FAST/ELISA) when indicated (inhalants, foods, stings, or when skin testing not possible)
Total serum IgE for specified diagnoses (e.g., allergic bronchopulmonary aspergillosis, hyper-IgE syndromes)

Documentation Required

Coverage contingent on medical necessity

Coverage contingent on medical necessity and documentation: Final claim payment is contingent upon member benefits, eligibility at time of service, and adequate clinical documentation that meets the policy’s medical necessity criteria. Absent documentation or lack of medical necessity may result in denial even if an appropriate code is billed.

Verify member eligibility and benefits prior to service
Retain provider notes showing correlation of tests to clinical history, exposures, and physical findings
Document trials of conservative therapy and rationale for testing or immunotherapy

MRT/LEAP is categorized in the policy as investigational/not covered for diagnosis of food allergy due to insufficient evidence

Method noteMRT measures cellular mediator release in vitro rather than specific IgE antibodies in serum

Double Blind Food Challenge Test — definition

DefinitionDouble Blind Food Challenge is a controlled ingestion test in which both the patient and physician are unaware of the food administered to eliminate bias

PurposeUsed to confirm or exclude food allergy by objective, blinded challenge

ContextClassified among in vivo methodologies alongside food challenges and used when diagnostic confirmation is needed

Bronchial Challenge Test — definition

DefinitionBronchial Challenge Test uses histamine or methacholine to determine airway hyper-responsiveness; volatile chemicals may be used for occupational exposures

IndicationPerformed when it is necessary to determine if the patient has hyper-responsive airways

Method classCategorized as an in vivo provocation test (bronchial provocation) in the policy definitions

Patch Test / Photo Patch Test — definition

Patch Test definitionPatch Test: suspected allergens applied to the patient's back under a dressing for 48 hours, then examined for delayed hypersensitivity reactions

Photo Patch Test definitionPhoto Patch Test: similar application for 48 hours followed by ultraviolet light exposure to detect photosensitization; a positive test produces a more severe reaction at the patch site than surrounding skin

Use caseUsed to identify allergens causing contact dermatitis and photosensitization

Serial Endpoint Testing (SET) — related entry

Definition (duplicate/related)Serial Endpoint Testing (SET) is intradermal testing with increasing antigen doses to determine the endpoint dilution and guide initiation of immunotherapy

Relation to IDTSET is a form of intradermal dilutional testing (IDT) and may be described interchangeably in the policy context

ApplicationReferenced specifically when used to determine safe starting doses for testing or immunotherapy

Leukocyte/Histamine release testing — definition & literature reference

DefinitionLeukocyte/Histamine release testing (LHRT) refers to in vitro assays that measure histamine release from leukocytes or basophils and are discussed in the literature section comparing them to standard allergy tests

Literature referencesPolicy cites studies and reviews (e.g., Griese et al. 1990; Krouse & Mabry 2003) that evaluate histamine release tests relative to standard diagnostic methods

Clinical stanceListed among investigational or non-standard tests in policy exclusions and literature due to limited validation for routine diagnostic use

Home Allergy Immunotherapy — definition & safety reference

DefinitionHome Allergy Immunotherapy refers to home-based subcutaneous or oral immunotherapy protocols where administration occurs outside a medical facility

Safety referencesPolicy cites surveillance and safety studies (e.g., Epstein et al. AAAAI/ACAAI surveillance 2008–2012; Hurst et al. 1999) and clinical care statements regarding home subcutaneous immunotherapy

Policy stanceHome administration is generally not recommended; at-home immunotherapy may be considered only in rare circumstances (e.g., remote venom immunotherapy) when benefits outweigh risks and appropriate safety documentation exists

Added clinical benefit to the policy.

2023-07-11Consensus Review

Updated references and coding table.

2022-09-30Consensus Review

No change to the policy statement; FEP references updated and ICD-10 code C90.0 removed.

2021-09-01Administrative Update

Added new ICD-10 codes L24A9, L24A0, Z91.014, and R05.1-R05.9 effective 2021-10-01.

2021-06-25Consensus Review

Policy statement unchanged; coding and references reviewed and updated.

2021-01-28Administrative Update

Deleted code 95071 from coding tables.

2020-08-11Minor Review

Policy statement changed and criteria added for repeat testing.

2020-05-29Administrative Update

Added new code 0178U to coding.

2020-05-14Consensus Review

Policy statement unchanged; coding reviewed with no changes; references reviewed and updated.

2020-04-01Administrative Update

Coding updated and new code 0165U added.