Currentmedical mutual - ohioPolicy AHS - G2056

Diagnosis of Idiopathic Environmental Intolerance

Defines coverage stance for laboratory and diagnostic testing related to Idiopathic Environmental Intolerance (IEI/MCS), lists tests that do not meet coverage criteria, reimbursement unit limits for specific lab CPT codes, background, guidelines, and referenced codes. Applies to all benefit types with government policy precedence noted.

Policy Summary

Payermedical mutual - ohio

PolicyDiagnosis of Idiopathic Environmental Intolerance

Policy CodePolicy AHS - G2056

Change Typerevised background/guidelines/references (12/04/2024)

Effective DateSep 18, 2015

Next Review Date

Key ActionVerify the member's benefit coverage and applicable government (LCD/NCD/state Medicaid) policies before ordering or billing tests.

POLICY UPDATE CHANGES

12/04/2024: Reviewed and Updated background, guidelines and recommendations, and evidence-based scientific references.

11Not-covered item lines in part 1

10CPT codes with unit limits

~40Procedure codes listed

1Breath test CPT code listed (91065)

0Coverage changes in revision

Coverage Summary

This policy (AHS - G2056) addresses coverage for laboratory and diagnostic testing related to Idiopathic Environmental Intolerance (IEI; formerly Multiple Chemical Sensitivity). The policy scope defines a mixed coverage stance: tests and panels specifically intended to confirm IEI or the enumerated specimen screenings do not meet coverage criteria (see list below). The policy effective date is 2015-09-18 with the most recent review on 2024-12-04 and a literature review that did not change coverage determinations (revision note 12/04/2024).

Examples of not-covered testing include screening of blood, saliva, serum, plasma, urine, and/or stool for volatile solvents, organic acids, organophosphates, phthalates and parabens; profiling of chlorinated pesticides (including DDE and DDT) in asymptomatic individuals; micronutrient, vitamin/mineral, and other nutritional profiling in asymptomatic individuals or general encounters without abnormal findings; metals testing in asymptomatic individuals; and use of breath hydrogen/methane testing for the listed non-covered indications. The policy also specifies per-date-of-service unit limits for select CPT codes (for example, 83918 max 2 units, 83919 max 1 unit, 83921 max 2 units, and other listed unit limits). Claims for the excluded tests may be denied as not meeting coverage criteria.

Not Covered / Does Not Meet Coverage Criteria

The following do not meet coverage criteria in all circumstances unless otherwise specified:

ALL of the following

Laboratory tests designed to confirm the diagnosis of idiopathic environmental intolerance
All circumstances
Screening of blood, saliva, serum, plasma, urine, and/or stool samples for volatile solvents, organic acids, and organophosphates
All circumstances
Profiling of phthalates and parabens using a blood, serum, plasma, saliva, urine, and/or stool sample
All circumstances
For asymptomatic individuals, profiling of chlorinated pesticides, including DDE and DDT, using a blood, serum, plasma, saliva, urine, and/or stool sample
Asymptomatic individuals
In asymptomatic individuals and/or during general encounters without abnormal findings, testing of blood, serum, plasma, saliva, urine, and/or stool samples for carnitine sufficiency, oxidative stress and antioxidant sufficiency, detoxification adequacy, methylation sufficiency status, lipoic acid and CoQ10 sufficiency, and/or intestinal hyperpermeability

The policy states that the following specimen types and test profiles are considered not covered as described: screening of blood, saliva, serum, plasma, urine, and/or stool for volatile solvents, organic acids, and organophosphates; profiling of phthalates and parabens from these specimen types; profiling of chlorinated pesticides (including DDE and DDT) in asymptomatic individuals; micronutrient, vitamin/mineral, and nutritional analyses in asymptomatic individuals or during general encounters without abnormal findings; and testing of blood, serum, urine, cerebrospinal fluid, fingernails, hair, and/or stool for metals in asymptomatic individuals. Additionally, breath hydrogen and/or methane tests are listed as not meeting coverage for the enumerated clinical indications (eg, IEI, food sensitivities, SIBO, digestive disorders, and others).

Coverage Determination Summary

Coverage determination summary (referenced from Part 1)

No modifications to coverage criteria were necessary after literature review (per revision history).

Coverage criteria remain as stated in the policy (no changes from the literature review dated 12/04/2024).

Coding

Applicable CPT/HCPCS Procedure Codes (listed in document part 1)CPT

82108	Aluminum
83918	Organic acids; total, quantitative, each specimen
83919	Organic acids; qualitative, each specimen
83921	Organic acid, single, quantitative
82127	Amino acids; single, qualitative, each specimen
82136	Amino acids, 2 to 5 amino acids, quantitative, each specimen
82139	Amino acids, 6 or more amino acids, quantitative, each specimen
84585	Vanillylmandelic acid (VMA), urine
83150	Homovanillic acid (HVA)
83497	Hydroxyindolacetic acid, 5-(HIAA)

1–10 of 11

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Applicable CPT / HCPCS Procedure Codes (listed in document)mixed

82108	Aluminum
82127	Amino acids; single, qualitative, each specimen
82136	Amino acids, 2 to 5 amino acids, quantitative, each specimen
82139	Amino acids, 6 or more amino acids, quantitative, each specimen
82300	Cadmium
82379	Carnitine (total and free), quantitative, each specimen
82380	Carotene
82441	Chlorinated hydrocarbons, screen
82495	Chromium
82507	Citrate

1–10 of 42

1/5

Provider Actions

Documentation Required

Verify benefit and applicable government policy

Application of coverage criteria is dependent upon the individual's benefit coverage; if government policy (LCD/NCD/state Medicaid) conflicts, the government policy supersedes. Providers should verify current policies at the CMS Medicare Coverage Database and applicable state Medicaid sites.

Billing Rule

Unit limits for specified CPT codes

Per date of service unit maximums are allowed for the listed CPT codes.

83918 — max 2 units per date of service
83919 — max 1 unit per date of service
83921 — max 2 units per date of service
82127 — max 1 unit per date of service

Background & Evidence

IEI (formerly MCS) is described as a subjective condition marked by recurrent, nonspecific symptoms attributed to low-level exposures without consistent objective diagnostic findings or reliable laboratory tests. Multiple specialty societies and consensus documents have questioned the validity of IEI testing and recommend avoiding unnecessary or nonvalidated tests.

The policy notes that no reliable or characteristic laboratory abnormalities have been consistently linked to IEI, and that many commonly used proprietary multi-analyte panels (for example, organic acid profiles, comprehensive nutrient panels, and multi-analyte bloodspot profiles) and breath tests (including hydrogen/methane breath testing offered in SIBO or other profiles) lack validated clinical utility for diagnosing IEI. Laboratory-developed tests (LDTs) used for some of these panels require in-house validation under CLIA '88 and are not FDA-cleared.

Evidence summary

Unsupported block type: paragraph

Definitions

Unsupported block type: list

Revision History

12/04/2024revisionLatest

Reviewed and Updated background, guidelines and recommendations, and evidence-based scientific references. Literature review did not necessitate any modifications to coverage criteria. No material coverage changes occurred.

Policy Summary

Payermedical mutual - ohio

PolicyDiagnosis of Idiopathic Environmental Intolerance

Policy CodePolicy AHS - G2056

Change Typerevised background/guidelines/references (12/04/2024)

Effective DateSep 18, 2015

Next Review Date

Key ActionVerify the member's benefit coverage and applicable government (LCD/NCD/state Medicaid) policies before ordering or billing tests.

On This Page

Asymptomatic individuals or general encounters without abnormal findings

In asymptomatic individuals and/or during general encounters without abnormal findings, testing of blood, serum, plasma, saliva, urine, and/or stool samples for vitamin sufficiency, mineral sufficiency, and/or nutritional analysis

Asymptomatic individuals or general encounters without abnormal findings

Breath hydrogen/methane tests DO NOT MEET COVERAGE for these indications

Idiopathic environmental intolerance
Food allergies and sensitivities
Bacterial overgrowth, including but not limited to, small intestinal bacterial overgrowth (SIBO)
Digestive disorders
Constipation, diarrhea, or flatulence
Neurological/neuromuscular disorders
Rosacea
Obesity
As part of a wellness visit and/or general encounter without abnormal findings

In asymptomatic individuals and/or during general encounters without abnormal findings, testing of blood, serum, urine, cerebrospinal fluid, fingernails, hair, and/or stool sample for metals

Asymptomatic individuals or general encounters without abnormal findings

82136 — max 2 units per date of service

82139 — max 2 units per date of service

84585 — max 1 unit per date of service

83150 — max 1 unit per date of service

83497 — max 1 unit per date of service

82656 — max 1 unit per date of service

Denial Risk

Claims for excluded tests risk denial

Claims for laboratory tests intended to confirm IEI or for the enumerated specimen screenings may be denied as not meeting coverage criteria.

Screening for volatile solvents, organic acids, and organophosphates
Profiling of phthalates and parabens
Chlorinated pesticides (including DDE and DDT) in asymptomatic individuals
Micronutrient/nutritional profiling (vitamin/mineral, carnitine, oxidative stress, detoxification, methylation, lipoic acid, CoQ10) in asymptomatic individuals or general encounters without abnormal findings
Metals testing in asymptomatic individuals
Breath hydrogen/methane testing for the listed non-covered indications (eg, IEI, food sensitivities, SIBO, digestive disorders, constipation/diarrhea/flatulence, neurological disorders, rosacea, obesity, wellness visits without abnormal findings)

Documentation Required

Follow applicable state/federal policies

If conflict exists between this policy and government policies (LCD/NCD/state Medicaid), government policy will be used for determination; providers should reference CMS/Medicaid sites for up-to-date policies.

Documentation Required

Laboratory-developed tests (LDTs) regulatory note

Laboratory-developed tests (LDTs) must be validated and performed in-house under CLIA '88 as high-complexity tests; they are not approved or cleared by the U.S. Food and Drug Administration, although FDA clearance is not required for clinical use.