Plan product and benefit application

This policy applies to Commercial products. Applicability to Medicaid/OHP and Medicare is described in the policy (Medicaid/OHP follow OHP rules when applicable; Medicare members may follow separate Medicare policy).

Prior authorization / documentation expectations (implied)

Prior authorization is not explicitly required in this section, but testing should be targeted to suspected allergens after an allergy-focused history and may require documentation to demonstrate medical necessity.

• Testing should be focused on foods or inhalants suspected of provoking the reaction and not be used as indiscriminate screening.
• Testing must be performed by personnel with appropriate competencies and facilities to manage anaphylaxis when skin testing is performed.

Annual frequency limits for allergy testing

The policy defines cumulative annual reimbursement limits for specified CPT code groups; providers should check benefits/prior authorization if limits may be exceeded.

• Percutaneous tests (95004, 95017, 95018): cumulative total of 70 per calendar year.
• Intracutaneous tests (95024, 95027, 95028): cumulative total of 40 per calendar year.
• Skin patch tests (95044): cumulative total of 80 per calendar year.
• Allergen-specific IgE serum tests for inhalant allergies (86003, 86008): cumulative total of 40 per calendar year.
• Allergen-specific IgE serum tests for food allergies (86003, 86008): cumulative total of 12 per calendar year.

Prior authorization for unlisted codes

Prior authorization is recommended for unlisted codes (e.g., 95199) or for potentially covered services submitted with unlisted codes to avoid post-service denial; unlisted codes are reviewed at claim level.

• All unlisted codes are reviewed for medical necessity, correct coding, and pricing at the claim level.
• Prior authorization is recommended to avoid post-service denial when an unlisted code is used for a potentially covered service.

Step therapy

No step therapy requirements are specified in this policy.

Preferred diagnostic sequence

Use validated tests (skin prick/puncture testing, serum allergen-specific IgE, and oral food challenge when indicated) before considering non-standard or unproven tests.

• Unproven or non-standardized tests are discouraged and listed as not medically necessary.

Preferred initial diagnostic modality

Skin testing (percutaneous/prick) is described as an ideal first-line investigation for IgE-mediated allergies due to high sensitivity and high negative predictive value; use serum sIgE when skin testing is unsafe or not possible.

• Perform skin testing when feasible; use serum allergen-specific IgE if the patient has widespread skin disease, cannot stop suppressive medications, cannot cooperate, or has high anaphylaxis risk.

Required clinical documentation

Clinical documentation of allergic or infectious symptoms is required to support in vitro allergy testing.

• Examples: urticaria, angioedema, ocular pruritus, wheezing, and/or anaphylaxis.

Documentation when skin testing is not possible

If skin testing is inconclusive or cannot be performed, document the specific reason (e.g., widespread skin disease, ongoing suppressive medication that cannot be stopped, inability to cooperate, or unusually high anaphylaxis risk).

• Acceptable reasons include dermatographia, generalized eczema, need for ongoing antihistamines or beta blockers that cannot be held, small child or inability to cooperate, or high anaphylaxis risk.

Clinical documentation expectations

Perform and document an allergy-focused history to justify testing; testing should be focused on suspected allergens and performed by qualified personnel with facilities to manage anaphylaxis when performing skin tests.

• Document the allergy-focused clinical history and the suspected allergens targeted for testing.
• Ensure personnel performing tests have appropriate competencies and emergency capabilities.

Frequency limit documentation

Documentation should support the number and type of tests billed and that they fall within the policy's annual frequency limits and code groups.

• When billing CPTs that specify number of tests (e.g., 95018, 95024, 95027, 95028, 95044, 86003, 86008), include the number of tests performed.
• Keep records showing tests were directed at suspected allergens and consistent with clinical indications.

Documentation and coding details

Claims for allergy testing must specify the number of tests where indicated and will be reviewed for medical necessity, correct coding, and pricing; unlisted codes are subject to claim-level review.

• Provide test counts for CPTs that require 'specify number of tests' (e.g., intracutaneous and patch codes).
• Be aware that coding combinations may be subject to NCCI edits and MUEs.

Denial risk for unsupported in vitro testing

In vitro allergy testing is considered not medically necessary when the policy criteria for in vitro testing are not met (lack of clinical documentation of allergic/infectious symptoms or lack of documented skin test inconclusive/not possible), which may result in claim denial.

• Providers must meet both clinical symptom documentation and one of the skin test criteria to justify in vitro testing.

Denial risk for multiallergen IgE screening (86005)

Multiallergen IgE screening (CPT 86005) is listed as not medically necessary and may be denied if billed.

• Policy states multiallergen testing does not identify specific antigens and is considered not medically necessary.

Denial risk for unsupported tests

Tests listed as not medically necessary in the policy (e.g., ALCAT, applied kinesiology, IgG/IgG4 testing, leukocyte histamine release test, hair analysis, provocation-neutralization) are unsupported and may be denied.

• The policy lists a non-exhaustive set of tests considered not medically necessary and lacking sufficient evidence.

ALCAT/cytotoxic testing coding denial (83516)

When CPT 83516 is billed to represent ALCAT or cytotoxic food testing, it is considered not medically necessary per this policy and may be denied.

• 83516 is explicitly noted as being used to represent ALCAT/cytotoxic food testing and is considered not medically necessary in that context.

Denial risk for unlisted codes

If an unlisted code is submitted for non-covered services addressed in this policy, it will be denied as not covered.

• All unlisted codes are reviewed at claim level for medical necessity, coding, and pricing.
• Prior authorization is recommended when an unlisted code might represent a potentially covered service to avoid post-service denial.