Priority Health Allergy Testing Policy Update

Coverage Criteria

Medically necessary tests

Covered when ALL of the following are met for listed tests:

Medically necessary allergy tests: IgE specific antibody testing (e.g., RAST, micro‑ELISA, immunocap) when clinically indicated for history of severe urticaria, hives, or severe allergy and when skin testing is inappropriate; skin tests (scratch, intradermal, pricks); patch application tests; drug provocation (provocation) testing; Skin Endpoint Titration (SET) — effective for quantifying patient sensitivity and providing a safe starting dose for immunotherapy but not shown to guide a final therapeutic dose; Nitric Oxide Breath Analysis for management of asthma.

See related Billing & coding policy for allergy injections / immunotherapy.

Not medically necessary / unproven

The following tests and therapies are considered not medically necessary/unproven:

Not medically necessary / unproven tests and therapies: Cytotoxicity testing (Bryan's test); urine autoinjection (autogenous urine immunization); provocation and neutralization testing for food allergy (Intracutaneous Progressive Dilution Food Test, IPDFT); Antigen Leukocyte Cellular Antibody Test (ALCAT); electrodermal testing or electro‑acupuncture; applied kinesiology (muscle strength testing); reaginic pulse testing; total serum IgG/IgA/IgM and testing of specific IgG antibodies; lymphocyte subset counts; lymphocyte function assays; lymphocyte transformation test (LTT); cytokine assays (including Th1/Th2 ratio); Natural Killer (NK) cell assays; food immune complex assay (FICA); leukocyte histamine release testing; body chemical analysis; sublingual immunotherapy (SLIT) aqueous formulations and SLIT allergy tablets not approved by the FDA; Nitric Oxide Breath Analysis for diagnosis of asthma; Clarifix® cryotherapy device to treat rhinitis; RhinAer® radiofrequency device to treat rhinitis; rhinophototherapy (intranasal phototherapy); repository emulsion therapy.

Some excluded therapies (e.g., RhinAer, Clarifix) are device‑based; repository emulsion therapy has historical safety concerns and limited supporting evidence.

Product application and applicability

Coverage is subject to member-specific benefits and medical necessity determinations.

General applicability: Policy applies to HMO/EPO, POS, PPO, ASO, Individual, Medicare, and Medicaid products subject to member‑specific benefits; group‑specific policy will supersede when applicable.

If there is a conflict with a plan document, the plan document governs; for Medicaid/Healthy Michigan, coverage is based on Michigan Medicaid Fee Schedule and Provider Manual guidance.

The following interventions are explicitly excluded from coverage for treatment of rhinitis or as allergy therapies: use of the RhinAer® radiofrequency device (Aerin Medical Inc.), the Clarifix® cryotherapy device, rhinophototherapy (intranasal phototherapy), and repository emulsion therapy. These exclusions reflect the policy's assessment of insufficient evidence and safety concerns for these modalities in the management of rhinitis and related allergic conditions.

Laboratory testing is subject to laboratory benefits and specific exclusions. 82785 (Gammaglobulin; IgE) is listed as not covered for Priority Health Medicaid. In addition, the policy identifies multiple specialized assay and immunoassay procedure codes as Not Covered (see coding section), reflecting that these laboratory methods are excluded when used for services designated as not covered under this policy.

The policy considers a number of tests and therapies not medically necessary or unproven for allergy evaluation or management. Examples include: ALCAT (antigen leukocyte cellular antibody test), cytotoxicity testing (Bryan's test), electrodermal testing, applied kinesiology, reaginic pulse testing, total serum IgG/IgA/IgM and specific IgG testing, lymphocyte subset/function assays and lymphocyte transformation tests, cytokine assays, NK cell assays, food immune complex assays (FICA), leukocyte histamine release, body chemical analysis, and sublingual immunotherapy (SLIT) aqueous formulations and non–FDA‑approved SLIT tablets. These services are subject to denial when billed for indications listed as not medically necessary.

Selected laboratory and specialized assay CPT/HCPCS codes are listed under 'Not Covered Services' and are considered not covered when used to perform services the policy designates as Not Covered. Examples include multiple immunoassay codes (e.g., 83516, 83518, 83519, 83520), complement testing (86160–86162), immune complex assays (86332), cellular function and lymphocyte assays (86352, 86353, 86356), leukocyte histamine release (86343), flow cytometry markers (88184–88185), and immunohistochemistry/immunofluorescence procedures (88342–88346). These codes are referenced to guide billing and to indicate tests that will not be covered under this policy when billed for excluded services.

Coding

CPT/HCPCS CodesCPT

86001	Allergen specific IgG 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 and intracutaneous, sequential and incremental, with venoms, immediate type reaction, including test interpretation and report, specify number of tests.
95018	Allergy testing, any combination of percutaneous and intracutaneous, sequential and incremental, with drugs or biologicals, immediate type reaction, including test interpretation and report, specify number of tests.
95024	Intracutaneous (intradermal) tests with allergenic extracts, immediate type reaction, including test interpretation and report by a physician, specify number of tests.
95027	Intracutaneous (intradermal) tests, sequential and incremental, with allergenic extracts for airborne allergens, immediate type reaction, including test interpretation and report by a physician, specify number of tests.

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Not covered (Priority Health Medicaid)CPTNot Covered

82785

Gammaglobulin; IgE (Not covered for Priority Health Medicaid Testing).

ICD-10 Codes that may support medical necessityICD-10

D69.0	Allergic purpura.
J30.0-J30.9	Vasomotor and allergic rhinitis.
J45.20-J45.998	Asthma.
L50.0-L50.9	Urticaria (allergic/idiopathic/contact/unspecified).
Z01.82	Encounter for allergy testing.

Covered allergy testing codes (selected list)CPTCovered

86001	Allergen specific IgG 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
95024	Intracutaneous (intradermal) tests with allergenic extracts, immediate type reaction, including test interpretation and report by a physician, specify number of tests
95027	Intracutaneous (intradermal) tests, sequential and incremental, with allergenic extracts for airborne allergens, immediate type reaction, including test interpretation and report by a physician, specify number of tests

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Additional testing and molecular codesCPT | HCPCSCovered

95070	Inhalation bronchial challenge testing
95076	Ingestion challenge test; initial 120 minutes of testing
95079	Ingestion challenge test; each additional 60 minutes
0605U	Allergy and immunology (hereditary alpha tryptasemia), DNA, analysis of TPSAB1 gene copy number variation using digital PCR

Immunotherapy and related supervision/desensitization codesCPTCovered

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 including provision of allergenic extract; single injection
95125	Professional services for allergen immunotherapy including provision of allergenic extract; two or more injections
95132	Professional services for allergen immunotherapy including provision of extract; three stinging insect venoms
95133	Professional services for allergen immunotherapy including provision of extract; four stinging insect venoms
95134	Professional services for allergen immunotherapy including provision of 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)
95145	Supervision of preparation and provision of antigens for allergen immunotherapy; single stinging insect venom
95146	Supervision of preparation and provision of antigens for allergen immunotherapy; two single stinging insect venoms

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Codes listed as Not Covered / laboratory and specialized assays (selected list)CPT | HCPCSNot 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
83519	Immunoassay; quantitative, by radioimmunoassay (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; each multiplex antibody stain procedure

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Explicit Medicaid not-covered laboratory testCPTNot Covered

82785

Gammaglobulin; IgE

inv-16: Skin Endpoint Titration (SET) guidance

UtilitySET is effective for quantifying patient sensitivity and for providing a safe starting dose for immunotherapy.

LimitationSET has not been shown to be an effective guide to determine a final therapeutic dose.

ContextListed among medically necessary allergy tests when clinically indicated (policy identifies SET as a tool used in immunotherapy initiation).

inv-17: Ingestion challenge time increments

Initial time increment95076 — ingestion challenge test; initial 120 minutes of testing.

Provider Actions & Requirements

Denial Risk

Denial Triggers

Services listed as not medically necessary in this policy may result in claim denial. Providers should review this list before ordering or billing for allergy testing or immunotherapy.

Cytotoxicity testing (Bryan's test)
Urine autoinjection (autogenous urine immunization)
Provocation testing and neutralization therapy for food allergy (IPDFT)
Antigen leukocyte cellular antibody test (ALCAT)
Electrodermal testing / electro-acupuncture
Applied kinesiology / muscle strength testing
Reaginic pulse testing
Total serum IgG, IgA, IgM testing for allergy
Specific IgG antibody testing for allergy
Lymphocyte subset counts, lymphocyte function assay, lymphocyte transformation test (LTT)
Cytokine assays / Th1/Th2 ratio, Natural Killer cell assays, Food immune complex assay, Leukocyte histamine release testing
Body chemical analysis

Background

Allergy testing, evaluations, and immunotherapy are eligible for coverage according to the member’s plan schedule of covered services; however, coverage is limited to standard, evidence‑based testing and treatments. Nonstandard methods and therapies (for example, repository emulsion therapy, intranasal phototherapy, and other services listed as not medically necessary) are excluded. Applicability of coverage is subject to the member’s specific benefits and applicable product rules.

Definitions

inv-27: Skin Endpoint Titration (SET) — definition/description

TermSkin Endpoint Titration (SET).

DefinitionA technique effective for quantifying patient sensitivity and for providing a safe starting dose for immunotherapy.

LimitationNot shown to be an effective guide to a final therapeutic dose.

inv-28: Repository emulsion therapy — definition/description

TermRepository emulsion therapy.

DefinitionAllergens are added to vegetable and mineral oils and injected intramuscularly with the intent of slow release at the injection site.

Safety/stance

OpenPayer

Allergy Testing / Immunotherapy

Coverage Criteria

Coding

Provider Actions & Requirements

Background

Definitions