Allergy Testing and Immunotherapy
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Policy governing medical necessity, quantity limits, investigational status, coding, and prior authorization requirements for allergy diagnostic testing and immunotherapy services for Capital Bluecross members and applicable products; affects providers ordering or administering allergy tests and immunotherapy.
No material clinical or coverage changes in this revision.
Coverage Criteria for Allergy Testing and Immunotherapy
inv-01: Allergy Testing — Medically Necessary
Considered medically necessary when ALL of the following are met:
From policy introductory criteria
Specific technique list and quantity limits
inv-02: Repeat Skin Testing — Medically Necessary
Repeat skin testing may be considered medically necessary in the following situations:
Repeat testing justified for new sensitizations in children
Adult repeat-testing indications
inv-03: Allergy Immunotherapy — Medically Necessary
Considered medically necessary when ALL of the following are met:
Immunotherapy prepared individually for airborne or insect venom allergens
Continuation requires documented benefit after one year
inv-04: Covered Services When Medically Necessary
Covered when medically necessary for appropriate diagnosis and management of listed allergic conditions and when supported by member benefits.
Coverage determination is based on medical necessity and benefit terms.
Other allergy tests and immunotherapy approaches are considered investigational due to insufficient evidence to support their use. Examples specifically listed in the policy include the nasal challenge test and the conjunctival (ophthalmic mucous membrane) challenge test, which are described as primarily research tools with limited established clinical utility, and at‑home administration of allergy immunotherapy (including preparation of serum and related services), which is considered investigational except in rare, individualized circumstances.
Procedure code S9338 is designated as investigational and therefore not covered under this policy; submission or use of this code may result in claim denial.
Procedure codes and policy statements that have been identified as managed by an external vendor have been removed from the payer's direct coverage statements. These vendor‑managed procedures are to be managed through the vendor's authorization and billing processes rather than through direct payer coverage statements.
Quantity level limits (QLLs) are applied to in vivo testing. A cumulative total of > 70 percutaneous (scratch/prick/puncture) tests or > 40 intracutaneous/intradermal tests per benefit period will be considered not medically necessary. Similarly, a cumulative total exceeding 80 Serial Endpoint/Test endpoints (SET, SDET, IDT) per benefit period will be considered not medically necessary.
Services that are determined to be not medically necessary or that are not included in a member's specific benefit program may be denied. The identification of a billing code in the coding section does not guarantee coverage; coverage is contingent on the member's benefit terms, eligibility on the date of service, and documentation that the service meets medical necessity criteria.
Coding: Procedure and Diagnosis Codes
| S9338 | Procedure Code S9338 (investigational and therefore not covered) |
| B44.81 | Allergic bronchopulmonary aspergillosis |
| D82.0 | Wiskott-Aldrich syndrome |
| H65.411 | Chronic allergic otitis media, right |
| H65.412 | Chronic allergic otitis media, left |
| H65.413 | Chronic allergic otitis media, bilateral |
| J30.0 | Vasomotor rhinitis |
| J30.1 | Allergic rhinitis due to pollen |
| J30.2 | Other seasonal allergic rhinitis |
| J30.81 | Allergic rhinitis due to animal (cat) (dog) hair and dander |
| J30.89 | Other allergic rhinitis |
| L24A9 | ICD-10 code added (09/01/2021 administrative update) |
| L24A0 | ICD-10 code added (09/01/2021 administrative update) |
| Z91.014 | ICD-10 code added (09/01/2021 administrative update) |
| R05.1 | ICD-10 code range added (09/01/2021 administrative update) |
| R05.9 | ICD-10 code range added (09/01/2021 administrative update) |
| C90.0 | ICD-10 code removed (09/30/2022) |
Provider Actions, Authorization, and Documentation
Confirm product-specific benefit rules before ordering
This policy applies only to specified Capital Blue Cross products and programs; benefit rules vary by product (for example, FEP PPO follows the FEP Medical Policy Manual, and CHIP/Capital Cares 4Kids is exempt from the quantity level limits). Confirm the member’s product and follow any product‑specific prior authorization or benefit direction before ordering or billing.
- FEP PPO: refer to the FEP Medical Policy Manual (link in policy).
- CHIP (Capital Cares 4Kids): quantity level limits do not apply.
Verify medical necessity and member benefits for listed codes
Ensure listed allergy testing and immunotherapy procedure codes are performed only when medically necessary and covered by the member’s benefit; verify eligibility and medical necessity prior to billing and, if required, obtain prior authorization per plan rules.
- Coverage is contingent on medical necessity and member benefit eligibility on the date of service.
- Providers must ensure services meet medical necessity and eligibility requirements prior to billing.
Use vendor-managed authorization pathways where indicated
Follow vendor authorization processes for procedures that the policy identifies as managed by a vendor instead of submitting those procedure requests directly to the payer (policy removed certain procedure codes as not applicable and vendor‑managed per the history).
Attempt conservative therapy before testing
Attempt empiric conservative therapy first; perform allergy testing only when symptoms are not adequately controlled by empiric conservative management and testing will correlate with the patient’s history and exposures.
- Symptoms must be inadequately controlled by empiric conservative therapy before testing is considered medically necessary.
- Testing must correlate to the individual’s history, risk of exposure, and physical findings.
No action specified
(Reserved)
No action specified
(Reserved)
Retain documentation demonstrating failure of empiric therapy and correlation to testing or immunotherapy
Document that symptoms were not controlled by empiric therapy, that testing correlates with the individual’s history/exposure/physical findings, and for immunotherapy document demonstrated hypersensitivity not manageable by avoidance/medication plus re‑evaluations every 6–12 months showing efficacy or a rationale for continuation.
- Testing documentation: failure of empiric therapy and correlation of test selection to history/exposure and physical findings; test technique/allergens must have proven efficacy.
- Immunotherapy documentation: demonstrated hypersensitivity not manageable by avoidance/medication; re‑evaluate every 6–12 months with evidence of efficacy, dosing adjustments, compliance, and adverse reaction monitoring.
Confirm eligibility and benefit coverage before billing
Verify member benefit program and eligibility on the date of service and document medical necessity; payment/coverage are determined by member benefits and medical necessity and claims may be denied if services are not covered under the member’s program or are not medically necessary.
- Identification of a code in the coding section does not denote coverage; coverage determined by member benefit terms.
- Confirm eligibility on the date of service and that services meet medical necessity before billing.
Follow current coding tables and vendor instructions
Use the policy’s updated coding tables and follow vendor instructions noted in the policy history; the policy history documents code additions/removals and administrative updates that affect coding and vendor‑managed procedures.
- Refer to policy history for code additions/removals (examples: new codes added, deletions, and codes removed effective 07/21/2025).
- Follow vendor‑managed procedure instructions for codes/statements removed from direct payer management.
Adhere to quantity level limits or risk denial
Do not exceed the policy’s quantity level limits; requests greater than 70 percutaneous, 40 intracutaneous, or 80 endpoint tests per benefit period will be considered not medically necessary and may be denied.
- Percutaneous tests: cumulative total up to 70 per benefit period.
- Intracutaneous/intradermal tests: cumulative total up to 40 per benefit period.
- Serial endpoint (SET/SDET/IDT) endpoints: cumulative total up to 80 per benefit period.
Document benefit to continue maintenance immunotherapy beyond one year
For ongoing immunotherapy, re‑evaluate every 6–12 months and discontinue maintenance if no documented clinical benefit after one year in maintenance unless a decrease in symptoms, increased tolerance, reduced medication use, or a reasonable explanation for lack of improvement is documented.
- Re‑evaluate efficacy, dosing, compliance, and adverse reactions every 6–12 months.
- Immunotherapy maintenance is considered not medically necessary after one year without documented benefit or justification.
Verify coverage even when codes appear in the policy
Remember that listing a code in the coding tables does not guarantee coverage; confirm that services are medically necessary and covered by the member’s benefit prior to providing or billing for services.
- Coverage depends on medical necessity and member benefit eligibility on the date of service.
- Claims for services that are not medically necessary or not included in the member’s benefit program may be denied.
Route vendor‑managed procedures through the vendor to avoid denials
Be aware that removal of procedure codes and statements from the payer policy because they are vendor‑managed may change authorization and billing pathways; route billing/authorizations through the vendor as instructed to avoid denials.
- Policy updates removed codes/statements that will be managed by the vendor; providers must follow vendor processes rather than billing the payer directly for those procedures.
- Failure to follow vendor routing may trigger denials.
Background and Scope
Allergic disorders produce a range of localized or systemic reactions and may be acute or chronic. Allergy testing includes in vivo methods — such as percutaneous (skin prick/scratch), intracutaneous/intradermal, patch, photo patch, bronchial challenge, and oral food challenge (open, single‑blind, or double‑blind) — and in vitro IgE analyses. Serial Endpoint Testing (SET) is an intradermal technique using increasing antigen doses to identify an endpoint dilution and may be used to guide initiation of immunotherapy. The policy scope covers diagnostic testing and immunotherapy services, the required documentation standards, applicable quantity limits, and investigational exclusions for Capital Bluecross benefit programs.
Definitions
Policy Revision History and Notes
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.