ModifiedCentenePolicy CP.MP.100

Allergy Testing and Therapy

Defines medical necessity, allowed/denied allergy testing procedures and allergen immunotherapy services for members of Centene-affiliated health plans, including documentation and testing limitations.

Policy Summary

PayerCentene

PolicyAllergy Testing and Therapy

Policy CodePolicy CP.MP.100

Change TypeMaterial coding and oversight updates

Effective Date

Next Review Date

Key ActionVerify correct ICD-10 linkage for CPT codes (including 86160-86162) and document that antigen preparation is overseen by a trained physician per policy before submitting claims.

SourceLink

POLICY UPDATE CHANGES

Added ICD-10 Table 7 with codes that do not support medical necessity for CPT codes 86160 through 86162.

Removed codes 86160, 86161 and 86162 from the not medically necessary table and later added them to the medically necessary CPT code list with diagnosis code requirements per the ICD-10 tables.

Updated criteria specifying that antigens are prepared by clinical staff directly overseen by a physician with training and expertise in allergen immunotherapy and noted requirement for other specialties to provide evidence of expertise consistent with AAAAI guidance.

Added ingestion (oral) challenge testing into Criteria I.C. and made grammatical updates to multiple criteria without impact to substance of criteria.

multipleCPT codes listed

3-yearRetesting interval

12-24 moBenefit assessment

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.

Not medically necessary examples

Coverage Criteria

Immunotherapy - Medical Necessity

Allergen immunotherapy administered in a medical facility is medically necessary when ALL of the following are met:

Immunotherapy indications: 1) Positive skin test or serologic evidence of specific IgE to relevant allergen; 2) Clinical condition such as allergic (extrinsic) asthma, perennial or seasonal allergic rhinitis/conjunctivitis, hymenoptera (bee/wasp/fire ant) venom allergy, dust mite–associated atopic dermatitis, or other aeroallergen-associated disease; 3) Symptoms occur after natural exposure to the implicated allergen or member has life‑threatening insect sting allergy; 4) Avoidance measures and/or pharmacologic therapy do not adequately control symptoms or cause unacceptable side effects; 5) Antigens for immunotherapy are prepared by clinical staff directly overseen by the physician who examined the patient and who has training and expertise in allergen immunotherapy (e.g., allergist/immunologist/otolaryngologist) or other specialties providing documented equivalent expertise per AAAAI guidance.

Includes venom immunotherapy and indication specifics referenced in background.

Rapid Desensitization / Rush Immunotherapy

Rapid desensitization is medically necessary when ALL of the following are met:

Rapid desensitization indications: 1) Documented allergy to a drug or biologic for which no reasonable alternative exists (examples: insulin, penicillin, horse/equine serum, sulfonamides, cephalosporins); 2) Positive clinical history with documented skin test reactivity or equivalent evidence of IgE‑mediated sensitivity when available; 3) The clinical need for the agent cannot be avoided and full‑dose therapy must be administered; 4) Procedure is performed under strict physician monitoring in a setting appropriate to the severity of the prior reaction (office with physician trained to treat anaphylaxis for most cases; ambulatory hospital setting when the initial reaction was severe); 5) Desensitization may be repeated for future required courses as clinically indicated.

Accelerated (rush) schedules may be used per professional guidance; may be appropriate for hymenoptera venom per AAAAI practice parameter.

Testing - Indications

In vitro and skin testing appropriateness — Covered when ANY of the following apply:

In vitro (specific IgE) testing indications: In vitro quantitative or semi‑quantitative specific IgE testing (e.g., CPT 86003, 86005, 86008) is indicated when: increased risk of anaphylaxis to skin testing exists (including when a licensed extract is unavailable), severe dermatographism or generalized eczema is present, patient cannot safely discontinue interfering medications, history is highly suggestive with negative/equivocal skin tests, patient is uncooperative due to mental/physical impairment, or when evaluating cross‑reactivity between insect venoms.

Total serum IgE reserved for specific clinical scenarios (e.g., ABPA, suspected immunodeficiency, consideration of omalizumab).

Percutaneous (prick/puncture) testing indications: Percutaneous skin testing (CPT 95004, 95017, 95018) is first‑line for immediate (IgE‑mediated) hypersensitivity when history supports exposure to tested antigens and testing can be performed safely under medical supervision.

Percutaneous testing remains test of choice in most clinical situations for immediate hypersensitivity.

Intradermal testing indications: Intradermal (intracutaneous) testing is appropriate when increased sensitivity is required after negative percutaneous tests and suspicion remains high, or for testing inhalants, hymenoptera venoms, and certain drugs (e.g., penicillins); perform only the minimal number of concentrations needed and consider skin end‑point dilution testing where indicated.

Medically Necessary: Testing and Immunotherapy

Procedures considered medically necessary when paired with supporting diagnoses per ICD-10 tables

Medically Necessary Procedure + Diagnosis: Selected CPT procedure codes listed as medically necessary in the policy (examples include in vitro specific IgE testing codes 86003/86005/86008; percutaneous and intradermal testing codes 95004/95017/95018/95024/95027/95028; immunotherapy professional service and supervision codes such as 95115, 95117, 95144, 95145–95149, 95165, 95170; and rapid desensitization 95180) are medically necessary only when the member has an ICD‑10 diagnosis from the corresponding ICD‑10 Code Table that supports medical necessity for that CPT code.

See CPT Code Table I and ICD‑10 Code Tables in the policy for full code‑to‑diagnosis mappings and required diagnosis linkage prior to claim submission.

Not Medically Necessary Procedures

Procedures considered not medically necessary

Not Medically Necessary Procedures: Procedure codes listed in CPT Code Table 2 (including but not limited to 86001, 86332, 86343, 86485, 86628, 95060, and PLA codes 0165U and 0178U) and the enumerated unproven tests and therapies (e.g., mediator release tests, certain alternative laboratory/diagnostic panels, repository emulsion therapy, non‑FDA sublingual immunotherapy, home administration of allergy immunotherapy, intracutaneous Rinkel Injection Therapy) are considered not medically necessary because safety or effectiveness have not been established.

Follow the current CPT Code Table 2 in the policy for the definitive list of not medically necessary procedure codes.

Administration and Personnel Qualifications

Clinical administration and personnel requirements

Safe Immunotherapy Administration: Immunotherapy must be individualized with build‑up schedules (conventional or accelerated) tailored per patient; administration must occur under physician supervision in facilities equipped and staffed to recognize and treat anaphylaxis; personnel preparing extracts must meet aseptic compounding qualifications (written test, media‑fill testing, gloved fingertip sampling, annual re‑evaluation) and maintain training and assessment records.

Build‑up typically entails approximately 14–28 weeks; duration of therapy and assessment of benefit should be individualized (see documentation and length‑of‑therapy criteria).

Medically necessary when diagnosis and oversight criteria are met

Policy includes requirements tying CPT code medical necessity to specific ICD-10 diagnoses and staff/oversight qualifications for immunotherapy preparation.

Diagnosis linkage and preparation oversight: CPT codes (for example 86160–86162) are considered medically necessary only when billed with ICD‑10 diagnosis codes that meet the requirements specified in the policy's ICD‑10 Code Tables; antigens used for immunotherapy must be prepared by clinical staff directly overseen by the physician who examined the patient and who has documented training and expertise in allergen immunotherapy (e.g., allergist, immunologist, otolaryngologist); other specialties must document equivalent training and expertise consistent with the AAAAI Allergen Immunotherapy Extract Preparation Instructional Guide.

Refer to ICD‑10 Code Table 7 for diagnoses that do NOT support medical necessity for 86160–86162 and to the policy coding tables for current code placement and diagnosis linkage rules.

The policy lists numerous specific antigens and examples that should not be used for diagnostic testing because they lack clinical relevance or evidence. Examples called out include newsprint, tobacco smoke, dandelion, orris root, phenol, alcohol, sugar, yeast, grain mill dust, wool (unless continuous/unprocessed exposure), soybean dust (except known occupational exposure), marigold, honeysuckle, green tea, fiberglass, chalk, cornstarch, cotton, smog, and formaldehyde.

Services specified as not medically necessary include non‑FDA‑approved sublingual immunotherapy, home administration of allergy immunotherapy, ingestion challenge testing performed by the patient at home, desensitization using whole‑body extracts for hymenoptera (except venom extracts), repository emulsion therapy, Rinkel intracutaneous desensitization (RIT), and other listed nonstandard practices.

The policy requires individualized duration of immunotherapy and specifies that if, after 12 to 24 months there is no noticeable clinical improvement (reduced symptoms, increased tolerance, or reduced medication use), failure may be presumed. Importantly, treatment will not be reimbursed after two years when there is no apparent clinical benefit.

The policy identifies an ICD‑10 code table (ICD‑10‑CM Code Table 7) listing diagnoses that do not support medical necessity when used as the linked diagnosis for CPT codes 86160, 86161, and 86162. Examples in this table include diagnoses such as allergic bronchopulmonary aspergillosis, various conjunctivitides, allergic and vasomotor rhinitis, chronic rhinitis, asthma, atopic dermatitis/eczema, allergic contact dermatitis, dermatitis due to substances taken internally, and related allergy status codes.

A long list of diagnostic tests and alternative therapies are explicitly considered unproven or not medically necessary. These include but are not limited to applied kinesiology/NAET, ALCAT automated food allergy testing, anti‑Fcε receptor antibody tests, candidiasis testing, chronic urticarial index, cytotoxic food testing (Bryan’s/ACT), cytokine assays, electrodermal testing, live cell analysis, mediator release test (MRT), provocation/neutralization testing, pulse test, Rebuck skin window, secretory IgA, VeriMAP Peanut Diagnostic, ophthalmic mucous membrane/conjunctival challenge tests performed outside indicated settings, and many other laboratory/alternative methods that the policy states lack established safety or effectiveness.

CPT Code Table 2 lists specific procedure codes designated as not medically necessary. Examples include 86001 (allergen‑specific IgG), 86332 (immune complex assay), 86343 (leukocyte histamine release test), 86485 (skin test; Candida), 86628 (antibody; Candida), 95060 (ophthalmic mucous membrane tests), and PLA codes 0165U and 0178U (peanut epitope ELISA assays).

The policy history and coding table revisions document prior listings of multiple CPT and PLA codes as not medically necessary and subsequent reorganization. Earlier revisions had placed codes such as 86160, 86161, 86162, 86332, 86343, 86485, 86628, 0165U, and 0178U in the not medically necessary table; later revisions removed 86160–86162 from the NMN table and re‑added them to the medically necessary list with required ICD‑10 diagnosis linkage per the ICD‑10 tables.

Coding and Diagnosis Tables

Covered CPT Codes - PercutaneousCPTCovered

95004	Percutaneous tests
95017	Percutaneous tests
95018	Percutaneous tests

Covered CPT Codes - IntradermalCPTCovered

95024	Intracutaneous (intradermal) testing
95027	Intracutaneous sequential/incremental testing / skin endpoint titration
95028	Intracutaneous testing

Covered CPT Codes - In vitro testingCPTCovered

86003	In vitro specific IgE test
86005	In vitro specific IgE test
86008	In vitro specific IgE test

Covered CPT Codes - Patch/Photo testingCPTCovered

95044	Patch testing
95052	Photo patch test
95056	Photo testing

Covered CPT Codes - Ingestion challengeCPTCovered

95076	Oral (ingestion) challenge
95079	Oral (ingestion) challenge

Covered CPT Codes (examples)CPTCovered

86003	Allergen specific IgE; quantitative or semiquantitative, crude allergen extract, each.
86005	Allergen specific IgE; qualitative, multiallergen screen.
86008	Allergen specific IgE; quantitative or semiquantitative, recombinant or purified component, each.
86160	Complement; antigen, each component.
86161	Complement; functional activity each component.

Covered CPT Codes (testing and immunotherapy)CPTCovered

95004	Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction; including test interpretation and report, specify number of tests.
95017	Allergy testing, any combination of percutaneous and intracutaneous with venoms, immediate type reaction; including test interpretation and report; specify number of tests.
95018	Testing, any combination of percutaneous and intracutaneous with drugs or biologicals, immediate type reaction; including test interpretation and report.
95024	Intracutaneous (intradermal) tests with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of tests.
95027	Intracutaneous tests, sequential and incremental, with allergenic extracts for airborne allergens, immediate type reaction, including test.
95028	Intracutaneous tests with allergenic extracts, delayed type reaction, including reading; specify number of tests.
95115	Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection.
95117	Professional services for allergen immunotherapy not including provision of allergenic extracts; 2 or more injections.
95144	Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy, single dose vial(s).
95145	Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single stinging insect venom.

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Not Medically Necessary Procedure CodesCPT|PLANot Covered

86001	Allergen specific IgG quantitative or semiquantitative each allergen.
86332	Immune complex assay.
86343	Leukocyte histamine release test (LHR).
86485	Skin test; candida.
86628	Antibody; Candida.
95060	Ophthalmic mucous membrane tests.
0165U	Peanut allergen-specific quantitative assessment of multiple epitopes using ELISA, blood, individual epitope results and probability of peanut allergy.
0178U	Peanut allergen-specific quantitative assessment of multiple epitopes using ELISA; blood, report of minimum eliciting exposure for a clinical reaction.

ICD-10 Diagnosis Codes Supporting Medical Necessity (grouped across CPT tables)ICD-10

B44.81	Allergic bronchopulmonary aspergillosis.
H10.0.11-H10.45	Conjunctivitis (various).
J30.0-J30.9	Vasomotor and allergic rhinitis.
J31.0	Chronic rhinitis.
J45.20-J45.998	Asthma.
L20.0-L20.9	Atopic dermatitis / eczema (various).
L23.0-L23.9	Allergic contact dermatitis.
L25.1-L25.9	Unspecified contact dermatitis.
L27.0-L27.9	Dermatitis due to substances taken internally.
L50.0-L50.9	Urticaria (various).

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CPT and other procedure codes referenced in policy history and coding tablesCPT

86160	Allergen-specific IgE (documented in CPT tables as moved between not medically necessary and medically necessary depending on diagnosis linkage)
86161	Allergen-specific IgE
86162	Allergen-specific IgE
86332	Noted in earlier revisions as not medically necessary (per revision history)
86343	Noted in earlier revisions as not medically necessary
86485	Noted in earlier revisions as not medically necessary
86628	Noted in earlier revisions as not medically necessary
0165U	Noted in earlier revisions as not medically necessary
0178U	Noted in earlier revisions as not medically necessary
86001	Added to the not medically necessary CPT code table in a prior revision

ICD-10 codes that do NOT support medical necessity for 86160-86162ICD-10Not Covered

B44.81	Allergic bronchopulmonary aspergillosis
H10.45	Conjunctivitis
J30.1	Allergic rhinitis
J30.9	Allergic rhinitis
J30.0	Vasomotor rhinitis
J31.0	Chronic rhinitis
J45.20	Asthma (code range through J45.998 listed)
L20.84	Intrinsic (allergic) eczema
L20.9	Atopic dermatitis, unspecified
L23.0	Allergic contact dermatitis

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Retesting interval — rarely necessary within 3 years

Retesting intervalRetesting with the same antigen(s) should rarely be necessary within a 3‑year period; exceptions include select children/adolescents and specific clinical circumstances.

Routine repetition of skin testsRoutine annual repetition of skin tests is not indicated and may be subject to medical review.

Serial total IgESerial repeat total IgE measurements will be subject to medical review and should not be performed routinely without justification.

Immunotherapy benefit assessment — evaluate benefit at 12-24 months; discontinue if no benefit after 24 months

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization / Ordering Expectations

Prior authorization and ordering: Allergy testing and immunotherapy must be ordered as part of a complete diagnostic evaluation. Ensure testing and immunotherapy are supported by a documented medical and immunologic history, face-to-face exam, and clear clinical indication (see documentation requirements).

Allergy testing/immunotherapy ordered only when part of complete diagnostic evaluation
Refer to state-specific unit limits; absent state rules, CMS NCCI MUE limits apply

Billing Rule

Medical Necessity by CPT When ICD-10 Support Present

Selected CPT codes in the allergy testing and immunotherapy CPT table (for example: 86003, 86005, 86008, 86160, 86161, 86162, 95004, 95017, 95018, 95024, 95027, 95028, 95044, 95148, 95149, 95165, 95170, 95180, 95199) are considered medically necessary only when the diagnosis code requirements in the ICD-10 code tables are met.

Background

Allergy testing identifies immunologic sensitivity to inhaled, ingested, injected, or contact substances and includes both immediate (IgE‑mediated) and delayed (cell‑mediated) approaches. Percutaneous (prick/puncture) testing is typically first‑line for immediate hypersensitivity, while intradermal (intracutaneous) testing is used when increased sensitivity is required (for example, after negative percutaneous testing or for venom and certain drug evaluations). Immunotherapy (repeated administration of specific allergens) is used to decrease allergic symptoms and inflammatory responses when indicated and must be individualized, with careful oversight during build‑up and maintenance phases.

Definitions

Definition - Allergen immunotherapy (repeated administration to induce protection)

Allergen immunotherapyRepeated administration of specific allergens to patients with IgE‑mediated conditions to provide protection against allergic symptoms and inflammatory reactions on exposure.

PurposeIntended to decrease symptom severity, increase tolerance to offending allergens, and reduce medication use over time.

Context of useAdministered when clinical history, positive testing, and failure of avoidance/pharmacotherapy support treatment; must be individualized and supervised in appropriate medical settings.

Definition - Intradermal (intracutaneous) testing

Intradermal testing definitionSkin tests performed when increased sensitivity is needed after negative percutaneous tests; appropriate for inhalants, hymenoptera venoms, and certain drugs.

Use considerations

Policy Summary

PayerCentene

PolicyAllergy Testing and Therapy

Policy CodePolicy CP.MP.100

Change TypeMaterial coding and oversight updates

Effective Date

Next Review Date

Key ActionVerify correct ICD-10 linkage for CPT codes (including 86160-86162) and document that antigen preparation is overseen by a trained physician per policy before submitting claims.

SourceLink

On This Page

Refer to CPT intradermal codes (e.g., 95024, 95027, 95028).

Benefit assessment timingEvaluate clinical benefit of immunotherapy at 12–24 months after initiation.

Documentation of benefit evaluationMedical record must document periodic clinical evaluation of treatment benefits and consideration of other treatment options if no benefit within 12–24 months.

Reimbursement linkageIf no apparent clinical benefit after the assessment period, continuation should be reconsidered and may not be reimbursed beyond policy limits.

Duration to assess failure — no noticeable clinical benefit after 12-24 months; non-reimbursed after 2 years without benefit

Definition of failureA presumption of failure may be made when, after 12–24 months of therapy, the patient does not experience a noticeable decrease in symptoms, increased tolerance to the allergen, or reduction in medication usage.

Non‑reimbursement after 2 yearsTreatment will not be reimbursed after two years when there is no apparent clinical benefit.

Required record elements for assessing failureDocumentation should include clinical evaluation of benefits, interpretation of test results, and plan for alternative treatments if no benefit is observed.

Build-up schedule duration — approximately 14-28 weeks

Typical build-up durationThe immunotherapy build-up schedule typically entails progressively increasing doses over approximately 14–28 weeks.

Conventional schedule characteristicsConventional schedules usually increase dose once per visit with visit frequency varying from one to three times weekly.

Accelerated schedule noteAccelerated schedules (rush/cluster) deliver several increasing-dose injections in a single visit to reach therapeutic dose earlier but may raise systemic reaction risk.

CPT codes are medically necessary only when supported by appropriate ICD-10 diagnosis per the policy code tables
Codes 86160, 86161, 86162 specifically require ICD-10 linkage (see ICD-10 Table 7 and CPT table notes)

Billing Rule

Diagnosis Linkage Required for 86160-86162

CPT codes 86160, 86161, and 86162 require diagnosis code linkage per the ICD-10 tables. These codes were removed from the not medically necessary list and are covered only when billed with supporting ICD-10 diagnoses that do not appear in the policy's 'does not support medical necessity' ICD-10 Table 7.

86160, 86161, 86162 require supporting ICD-10 codes and are not covered with diagnoses listed in ICD-10 Table 7
Review ICD-10 Table 7 for diagnoses that do not support medical necessity for these complement codes

Step Therapy

Therapy Escalation Before Immunotherapy

Therapy escalation before beginning allergen immunotherapy: immunotherapy is indicated only when there is positive testing for specific IgE to clinically relevant allergens and symptoms persist despite appropriate avoidance measures and pharmacologic therapy, or when pharmacologic therapy causes unacceptable side effects. Venom immunotherapy requires a history of systemic reaction/anaphylaxis to insect sting plus positive testing.

Immunotherapy indicated when avoidance/pharmacologic therapy fails OR pharmacologic therapy causes unacceptable side effects
Positive skin test or serologic evidence of specific IgE to relevant allergen required
Venom immunotherapy indicated for anaphylaxis after insect sting with positive skin or in vitro testing

Note

Build-up Scheduling Considerations

Build-up scheduling considerations: the build-up schedule must be individualized. Conventional schedules typically take approximately 14–28 weeks with one dose increase per visit (visits 1–3 times weekly). Accelerated schedules (rush or cluster) give several injections at increasing doses in a single visit, achieving therapeutic dose earlier but potentially increasing systemic reaction risk.

Conventional build-up: ~14–28 weeks, single dose increase per visit, visit frequency = 1–3 times/week
Accelerated (rush/cluster): multiple injections per visit to reach therapeutic dose sooner; watch for higher systemic reaction risk

Documentation Required

Required Documentation Elements

Required documentation elements: Medical records must include a complete medical and immunologic history, face-to-face exam, medical necessity rationale, test methodology, quantitative results (specific IgE in kIU/L or measured wheal/erythema in mm for skin tests), interpretation and how results will be used in the care plan, and periodic evaluation of treatment benefit (clinical re-evaluation at 3–5 years). If no benefit within 12–24 months consider other options; treatment will not be reimbursed after two years without apparent clinical benefit.

Complete medical and immunologic history and face-to-face physical exam documented
Medical necessity for the test clearly stated
In vivo testing: measure wheal and erythema sizes (mm) and record methodology
In vitro testing: report quantitative specific IgE results (kIU/L)
Interpretation and use of results in the patient care plan
Periodic evaluation of treatment benefits; if no benefit within 12–24 months consider stopping
Clinical re-evaluation at 3–5 years to determine need for continued immunotherapy

Documentation Required

Personnel Training Records

Personnel training records: personnel who prepare allergen extracts must meet competency standards (written aseptic technique test, annual media-fill or equivalent, gloved fingertip-thumb sampling tests, reinstruction if failed). Allergist offices must retain training, assessment results, evaluations, qualifications, and corrective actions for compounding staff.

Pass written test on aseptic technique and extract preparation
Annually pass media-fill or equivalent test and gloved fingertip-thumb sampling test
Reinstruction and reevaluation required if tests are failed
Maintain records of training, assessments, evaluations, qualifications, and corrective actions for all compounding personnel

Documentation Required

Immunotherapy Preparation Oversight Documentation

Immunotherapy preparation oversight documentation: document that antigens are prepared by clinical staff directly overseen by the physician who examined the patient and who has training and expertise in allergen immunotherapy (allergist, immunologist, otolaryngologist). Other specialties must provide evidence of equivalent training consistent with AAAAI/USP guidance.

Document physician oversight of antigen preparation and evidence of training/expertise
If non-specialists prepare antigens, include documentation of training consistent with AAAAI extract preparation guidance

Billing Rule

Medical Necessity Requirements for Immunotherapy

Medical necessity requirements for immunotherapy: immunotherapy is medically necessary only when all criteria are met: positive immediate hypersensitivity testing or in vitro specific IgE to clinically relevant allergens; symptoms consistent with exposure (rhinitis, conjunctivitis, allergic asthma, or life‑threatening insect allergy); and failure of or intolerance to avoidance/pharmacologic therapy. Do not give immunotherapy to patients with negative specific IgE results that do not correlate with clinical history.

Positive skin test or specific IgE to clinically relevant allergen required
Clinical symptoms after natural exposure or history of life‑threatening insect allergy
Failure of or unacceptable side effects from avoidance/pharmacologic therapy

Denial Risk

Retesting and Repeat IgE Measurement Caution

Retesting and repeat IgE measurement caution: routine repetition of skin tests (e.g., annually) is not indicated and retesting with the same antigen(s) should rarely be necessary within a three-year period except for specific exceptions (children/adolescents with documented food allergy needing follow-up, young children with prior negative skin tests, or persistent symptoms). Serial repeat total IgE testing will be subject to medical review; total IgE (CPT 82785) is generally not appropriate except for ABPA, select immunodeficiencies, atopic dermatitis with recurrent infections, or evaluation for omalizumab therapy.

Routine annual skin test repetition not indicated
Retesting within three years is rarely necessary; exceptions include specified pediatric scenarios
Serial repeat total IgE testing subject to medical review; CPT 82785 limited to specific indications

Denial Risk

Lack of Clinical Benefit Triggers Non-Reimbursement

Lack of clinical benefit triggers non-reimbursement: treatment will not be reimbursed after two years if there is no apparent clinical benefit (no noticeable decrease in symptoms, no increased tolerance, and no reduction in medication use).

If no clinical benefit within 12–24 months, consider discontinuing therapy
No reimbursement after two years without apparent clinical benefit

Billing Rule

Diagnoses That Do Not Support Medical Necessity for 86160-86162

Diagnoses that do not support medical necessity for 86160-86162: review ICD-10-CM Table 7 for specific codes that do not support medical necessity for complement testing (examples include allergic bronchopulmonary aspergillosis B44.81; conjunctivitis H10.45; allergic rhinitis J30.x; chronic rhinitis J31.0; asthma ranges J45.20–J45.998; atopic dermatitis and related codes L20.x, L23.x, L25.x, L27.x).

Do not bill 86160/86161/86162 with diagnoses listed in ICD-10 Table 7
Consult ICD-10 Table 7 in the policy for the full list of non-supporting diagnoses

Clinicians should narrow the area of investigation and perform the minimal number of intradermal tests necessary; typically two concentrations may be used.

Relation to percutaneous testingIntradermal testing is used when percutaneous (prick/puncture) tests (CPT 95004/95017/95018) are negative but clinical suspicion remains high.

Definition - Aseptic compounding personnel qualifications

Suggested qualificationsAseptic compounding personnel should pass a written test on aseptic technique and extract preparation and demonstrate understanding of hand hygiene, garbing, disinfection, aseptic technique, measurement/mixing, equipment use, and documentation.

Ongoing competencyPersonnel should annually pass a media‑fill (or equivalent) test and gloved fingertip‑thumb sampling; re‑instruction and re‑evaluation required after test failures.

RecordkeepingAllergist offices must keep records of training, assessment results, evaluations, qualifications, and any corrective actions for compounding personnel.

Definition - Accelerated immunotherapy (rush/cluster)

Accelerated (rush/cluster) immunotherapyAdministration of several injections at increasing doses during a single visit to achieve therapeutic dose earlier.

Benefit of accelerated schedulesOffers faster attainment of therapeutic dose compared with conventional build-up schedules.

Risk considerationAccelerated schedules may be associated with an increased risk of systemic reactions in some patients; selection should be individualized.

Definition - Antigen preparation oversight (physician-supervised preparation)

Physician oversight requirementAntigens for immunotherapy must be prepared by clinical staff directly overseen by the physician who examined the patient and who has training and expertise in allergen immunotherapy (eg, allergist/immunologist/otolaryngologist); other specialties must provide evidence of equivalent expertise per AAAAI guidance.

Documentation expectationRecord that preparation was performed under direct physician supervision and note the physician's relevant training or provided evidence of equivalent competency.

Reference guidancePreparation and oversight expectations align with AAAAI Allergen Immunotherapy Extract Preparation Instructional Guide and USP/compounding standards.