ModifiedPriority Health MedicarePolicy 91037

ALLERGY TESTING / IMMUNOTHERAPY

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This policy governs the medical necessity of allergy testing and immunotherapy services used to diagnose and manage allergic conditions for Priority Health Medicare members. Coverage remains subject to the member's specific benefits, applicable mandates, and plan terms.

Policy Summary

PayerPriority Health Medicare

PolicyALLERGY TESTING / IMMUNOTHERAPY

Policy CodePolicy 91037

Change TypeModified

Effective DateSep 1, 2026

Next Review DateN/A

Key ActionWhen prior authorization is required, submit documentation demonstrating that the drug, service, or procedure is medically necessary.

SourceLink

POLICY UPDATE CHANGES

Posterior nasal nerve ablation was deleted from this policy because it is now considered medically necessary and addressed under Priority Health Medical Policy 91653.

The policy added a defined policy scope and a reference to Medical Policy 91653 for posterior nasal nerve ablation.

Outdated references were removed.

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ModifiedPriority Health MedicarePolicy 91037

ALLERGY TESTING / IMMUNOTHERAPY

Customize your policy alerts

Sign up for priority_health_medicare Policy 91037 alerts

Get alerted when Policy 91037 changes without checking for updates manually.

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Policy Summary

PayerPriority Health Medicare

PolicyALLERGY TESTING / IMMUNOTHERAPY

Policy CodePolicy 91037

Change TypeModified

Effective DateSep 1, 2026

Next Review DateN/A

Key ActionWhen prior authorization is required, submit documentation demonstrating that the drug, service, or procedure is medically necessary.

SourceLink

POLICY UPDATE CHANGES

Posterior nasal nerve ablation was deleted from this policy because it is now considered medically necessary and addressed under Priority Health Medical Policy 91653.

The policy added a defined policy scope and a reference to Medical Policy 91653 for posterior nasal nerve ablation.

Outdated references were removed.

6Medically necessary allergy testing services

22Services or testing methods not medically necessary

19Immunotherapy codes listed

19Not medically necessary procedure codes

2CMS National Coverage Determinations

1IgE testing coverage caveat

Medical Necessity and Coverage Criteria

Medically necessary allergy testing

The following allergy tests are considered medically necessary when clinically indicated.

Eligible testing services

IgE specific antibody testing
- IgE specific antibody testing (for example, RAST, micro-Elisa, or immunocap) is clinically indicated for a history of severe urticaria, hives, or severe allergy.
- Skin testing is inappropriate.
Other medically necessary testing
- Skin tests, including scratch, intradermal, or prick testing.
- Patch application tests.
- Drug provocation testing.
- Skin endpoint titration (SET).
  SET may quantify patient sensitivity and establish a safe starting dose for immunotherapy; it has not been shown to guide the final therapeutic dose.
- Nitric oxide breath analysis for management of asthma.

Not medically necessary or unproven services

The following services have not been proven effective in diagnosing and/or treating allergies and are considered not medically necessary.

Not medically necessary services

Unproven allergy testing or treatment: Cytotoxicity testing (Bryan's test); urine autoinjection (autogenous urine immunization); provocation testing and neutralization therapy for food allergy, including Intracutaneous Progressive Dilution Food Test (IPDFT); Antigen Leukocyte Cellular Antibody Test (ALCAT); electrodermal testing or electro-acupuncture; applied kinesiology or muscle-strength testing of allergies; reaginic pulse testing or pulse testing for allergies; total serum immunoglobulin G (IgG), immunoglobulin A (IgA), or immunoglobulin M (IgM); testing of specific IgG antibody; lymphocyte subset counts; lymphocyte function assay; lymphocyte transformation test (LTT), including metal-ion testing for metal-induced hypersensitivity; cytokine or cytokine-receptor assays and Th1/Th2 cytokine ratio; natural-killer (NK) cell assay or activity; food immune complex assay (FICA); leukocyte histamine release testing; or body chemical analysis.
Unproven immunotherapy or other services: Sublingual immunotherapy (SLIT) aqueous formulations; SLIT allergy tablets that have not been approved by the FDA; nitric oxide breath analysis for diagnosis of asthma; rhinophototherapy (intranasal phototherapy); or repository emulsion therapy.
FDA-approved SLIT agents may be addressed under the appropriate Approved Drug List.

Individual consideration for experimental or investigational treatment

Individual consideration may allow coverage for certain otherwise excluded treatments when prior plan approval is obtained.

Individual consideration exception

The requested care or treatment is investigational yet promising for the condition.
Qualifying condition
- The condition is a terminal illness.
- The condition is a chronic, life-threatening, severely disabling disease causing serious clinical deterioration.
Prior plan approval is obtained before treatment.
Coverage determinations are made by a Priority Health medical director or clinical pharmacist.

Sublingual immunotherapy (SLIT) allergy tablets that have not been approved by the FDA are not considered medically necessary. FDA-approved agents may be addressed under the applicable Approved Drug List.

Nitric oxide breath analysis is considered medically necessary for asthma management when clinically indicated, but is not considered medically necessary when used to diagnose asthma.

The following allergy and immunology services are identified as not medically necessary: immunoassays; complement testing; immune-complex assays; immunohistochemistry and immunofluorescent studies; cellular function assays; flow cytometry; leukocyte histamine release testing; lymphocyte transformation testing; mononuclear cell antigen testing; unlisted allergy or clinical immunologic services billed for a service listed as not covered; and code 0604U for chronic recurrent angioedema testing.

Experimental, investigational, or unproven treatment is excluded unless an individual consideration exception is approved in advance. Individual review may be requested for investigational but promising care when the condition is terminal, or is a chronic, life-threatening, severely disabling disease causing serious clinical deterioration.

The following methods are considered not medically necessary because they have not been proven effective in diagnosing or treating allergies: cytotoxicity testing; urine autoinjection; food allergy provocation testing and neutralization therapy, including IPDFT; ALCAT testing; electrodermal testing or electro-acupuncture; applied kinesiology or muscle strength testing; reaginic pulse testing; total serum IgG, IgA, or IgM testing; specific IgG antibody testing; lymphocyte subset counts; lymphocyte function assays; lymphocyte transformation or metal ion testing; cytokine, cytokine receptor, and Th1/Th2 cytokine-ratio assays; NK cell assays or activity testing; FICA; leukocyte histamine release testing; body chemical analysis; aqueous SLIT; non-FDA-approved SLIT allergy tablets; nitric oxide breath analysis for asthma diagnosis; rhinophototherapy; and repository emulsion therapy.

The following codes are identified as not medically necessary: 83516, 83518, 83519, 83520, 86160, 86161, 86162, 86332, 88342, 88344, 88346, 86352, 88184, 88185, 86343, 86353, 95199, 86356, and 0604U. Code 95199 is not covered when billed for a service listed as not covered under this policy.

Coding and Coverage References

ICD-10 Codes that may support medical necessityICD-10

D69.0	Allergic purpura
H10.401-H10.409	Unspecified chronic conjunctivitis
H10.421-H10.429	Simple chronic conjunctivitis
H10.44	Vernal conjunctivitis
H16.261-H16.269	Vernal keratoconjunctivitis, with limbar and corneal involvement
H10.411-H10.419	Chronic giant papillary conjunctivitis
H10.45	Other chronic allergic conjunctivitis
H10.9	Unspecified conjunctivitis
J30.0-J30.9	Vasomotor and allergic rhinitis
J31.0-J31.2	Chronic rhinitis, nasopharyngitis and pharyngitis

1–10 of 37

1/4

TestingCPT

82785	Gammaglobulin; IgE
86001	Allergen specific IgG quantitative or semiquantitative, each allergen
86003	Allergen specific IgE; quantitative or semiquantitative, each allergen
86005	Allergen specific IgE; qualitative, multiallergen screen (dipstick, paddle or disk)
86008	Allergen specific IgE; quantitative or semiquantitative, recombinant or purified component, each
86021	Antibody identification; leukocyte antibodies
95004	Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, including test interpretation and report by a physician, specify number of tests.
95012	Nitric oxide expired gas determination
95017	Allergy testing, any combination of percutaneous (scratch, puncture, prick) and intracutaneous (intradermal), sequential and incremental, with venoms, immediate type reaction, including test interpretation and report, specify number of tests
95018	Allergy testing, any combination of percutaneous (scratch, puncture, prick) and intracutaneous (intradermal), sequential and incremental, with drugs or biologicals, immediate type reaction, including test interpretation and report, specify number of tests

1–10 of 22

1/3

ImmunotherapyCPT

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; two or more injections
95120	Professional services for allergen immunotherapy in prescribing physician's office or institution, including provision of allergenic extract; single injection
95125	Professional services for allergen immunotherapy in prescribing physician's office or institution, including provision of allergenic extract; two or more injections
95130	Professional services for allergen immunotherapy in prescribing physician's office or institution, including provision of allergenic extract; single stinging insect venom
95131	Professional services for allergen immunotherapy in prescribing physician's office or institution, including provision of allergenic extract; two stinging insect venoms
95132	Professional services for allergen immunotherapy in prescribing physician's office or institution, including provision of allergenic extract; three stinging insect venoms
95133	Professional services for allergen immunotherapy in prescribing physician's office or institution, including provision of allergenic extract; four stinging insect venoms
95134	Professional services for allergen immunotherapy in prescribing physician's office or institution, including provision of allergenic extract; five stinging insect venoms
95144	Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy, single dose vial(s) (specify number of vials)

1–10 of 19

1/2

National Coverage Determinations (NCDs)mixed

110.9	Antigens Prepared for Sublingual Administration
110.11	Food Allergy Testing and Treatment
110.12	Challenge Ingestion Food Testing
110.13	Cytotoxic Food Tests

Local Coverage Determinations (LCDs)mixed

L40056	Allergen Immunotherapy (AIT) with Subcutaneous Immunotherapy (SCIT)
A59981	Allergen Immunotherapy (AIT) with Subcutaneous Immunotherapy (SCIT)
L34063	RAST Type Tests
A57043	RAST Type Tests
L37800	Allergen Immunotherapy
A57678	Allergen Immunotherapy
L33261	Allergy Testing
A57531	Allergy Testing
L40048	Allergen Immunotherapy (AIT) with Subcutaneous Immunotherapy (SCIT)
A59973	Allergen Immunotherapy (AIT) with Subcutaneous Immunotherapy (SCIT)

1–10 of 28

1/3

ImmunotherapyCPTCovered

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; two or more injections
95120	Professional services for allergen immunotherapy in prescribing physician's office or institution, including provision of allergenic extract; single injection
95125	Professional services for allergen immunotherapy in prescribing physician's office or institution, including provision of allergenic extract; two or more injections
95130	Professional services for allergen immunotherapy in prescribing physician's office or institution, including provision of allergenic extract; single stinging insect venom
95131	Professional services for allergen immunotherapy in prescribing physician's office or institution, including provision of allergenic extract; two stinging insect venoms
95132	Professional services for allergen immunotherapy in prescribing physician's office or institution, including provision of allergenic extract; three stinging insect venoms
95133	Professional services for allergen immunotherapy in prescribing physician's office or institution, including provision of allergenic extract; four stinging insect venoms
95134	Professional services for allergen immunotherapy in prescribing physician's office or institution, including provision of allergenic extract; five stinging insect venoms
95144	Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy, single dose vial(s) (specify number of vials)

1–10 of 19

1/2

Not Medically NecessaryCPTNot Covered

83516	Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method
83518	Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, single step method (e.g., reagent strip)
83519	Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, by radioimmunoassay (e.g., RIA)
83520	Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified
86160	Complement; antigen, each component
86161	Complement; functional activity, each component
86162	Complement; total hemolytic (CH50)
86332	Immune complex assay
88342	Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure
88344	Immunohistochemistry or immunocytochemistry, per specimen; each multiplex antibody stain procedure

1–10 of 19

1/2

Provider Documentation and Billing Actions

Prior Authorization

Submit medical-necessity documentation

When prior authorization is required, submit a request demonstrating that the drug, service, or procedure is medically necessary. Applicable authorization criteria are available through Priority Health Prism under Authorizations > Authorization Criteria Lookup.

Prior Authorization

Obtain prior approval for individual consideration

Requests for individual consideration of experimental, investigational, or unproven treatment require prior plan approval. Coverage determinations are made by a Priority Health medical director or clinical pharmacist.

Documentation Required

Document the clinical indication and testing rationale

Policy Background and Scope

This policy addresses the medical necessity of diagnostic allergy testing and allergen immunotherapy used to diagnose and manage allergic conditions for Priority Health Medicare members. Coverage is subject to the member’s specific benefits, applicable federal or state requirements, and plan terms.

Relevant Terms and Treatment Methods

Skin Endpoint Titration (SET)

DefinitionSkin endpoint titration (SET) is an allergy testing method that quantifies patient sensitivity.

PurposeSET provides a safe starting dose for immunotherapy.

Policy treatmentSET is considered medically necessary, but it has not been shown to effectively guide the final therapeutic dose.

Sublingual Immunotherapy (SLIT)

DefinitionSublingual immunotherapy (SLIT) administers allergens under the tongue, generally on a daily basis.

Not medically necessaryAqueous SLIT formulations are not medically necessary.

Policy Summary

PayerPriority Health Medicare

PolicyALLERGY TESTING / IMMUNOTHERAPY

Policy CodePolicy 91037

Change TypeModified

Effective DateSep 1, 2026

Next Review DateN/A

Key ActionWhen prior authorization is required, submit documentation demonstrating that the drug, service, or procedure is medically necessary.

SourceLink

On This Page

Document the clinical indication for the allergy test. For IgE specific antibody testing, document a history of severe urticaria, hives, or severe allergy and why skin testing is inappropriate.

Documentation Required

Document the purpose of skin endpoint titration

When using skin endpoint titration, document that it is being used to quantify patient sensitivity and provide a safe starting dose for immunotherapy. The policy does not support using it as a guide to the final therapeutic dose.

Note

Confirm plan and Medicare requirements

Verify the member’s specific benefits and applicable CMS requirements before providing the service. This policy is informational, is not an authorization, and applicable federal or state mandates take precedence.

Billing Rule

Add explanatory notes for code 95199

Include explanatory notes with claims billed using unlisted allergy or clinical immunologic service or procedure code 95199.

Denial Risk

Use only medically necessary allergy services

Services listed as not medically necessary because they have not been proven effective in diagnosing or treating allergies are at risk for denial. This includes specified unproven testing and treatment methods, non-FDA-approved sublingual immunotherapy products, nitric oxide breath analysis for asthma diagnosis, rhinophototherapy, and repository emulsion therapy.

Denial Risk

Support IgE testing with a clinical indication

IgE specific antibody testing is medically necessary only when clinically indicated for a history of severe urticaria, hives, or severe allergy and skin testing is inappropriate. Claims that do not establish these conditions may be denied.

Denial Risk

Use the correct indication for nitric oxide testing

Nitric oxide breath analysis is medically necessary for management of asthma but is not medically necessary for diagnosis of asthma. Confirm and document the asthma-related purpose before billing code 95012.

Billing Rule

Do not use 95199 for a noncovered service

Code 95199 is not covered when billed for a service listed as not covered in this policy. The code’s unlisted-service reporting requirement does not establish coverage for an otherwise noncovered service.

Denial Risk

Seek approval for experimental or investigational treatment

Experimental, investigational, or unproven treatment is excluded unless an individual consideration exception is approved. An exception may be reviewed when the condition is terminal or is a chronic, life-threatening, severely disabling disease causing serious clinical deterioration, and the request requires prior plan approval.

FDA-approved tablets

SLIT allergy tablets that have not been approved by the FDA are not medically necessary; pharmacy coverage information for FDA-approved agents is provided through the appropriate Approved Drug List.

Repository Emulsion Therapy

DefinitionRepository emulsion therapy adds allergens to vegetable and mineral oils.

AdministrationThe oil-based preparation is injected intramuscularly.

Intended treatment methodThe intended effect is slow release of allergens at the injection site.

Policy treatmentThe therapy is outdated and was discontinued after it was found to have the potential to induce plasma cell myelomas.

Rhinophototherapy

DefinitionRhinophototherapy, also called intranasal phototherapy, is phototherapy directed at the nasal mucosa.

Proposed useIt has been proposed as a treatment for allergic rhinitis.

EvidenceThe treatment remains unproven because the available peer-reviewed literature is limited; NICE states that evidence on efficacy and safety is limited in quantity and quality and recommends use only in research.

Policy treatmentRhinophototherapy is considered not medically necessary.