CurrentProvidence Health PlanPolicy 152

Allergy Testing

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This Medicare medical policy governs coverage and medical-necessity determinations for allergy testing and related laboratory services for Providence Medicare Advantage members.

Policy Summary

PayerProvidence Health Plan

PolicyAllergy Testing

Policy CodePolicy 152

Change TypeReference update onlyno material clinical or coverage changes

Effective DateOct 1, 2026

Last ReviewSep 1, 2026

Next Review DateJun 1, 2027

Key ActionDocument the patient's specific medical problem, relevant findings, practitioner order, and how test results will directly guide management.

SourceLink

POLICY UPDATE CHANGES

The October 2026 interim update added the Noridian LCD L40324 and LCA A60361 to the policy references.

4General Medicare coverage requirements

83516

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CurrentProvidence Health PlanPolicy 152

Allergy Testing

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Sign up for Providence Health Plan Policy 152 alerts

Get alerted when Policy 152 changes without checking for updates manually.

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This Medicare medical policy governs coverage and medical-necessity determinations for allergy testing and related laboratory services for Providence Medicare Advantage members.

Policy Summary

PayerProvidence Health Plan

PolicyAllergy Testing

Policy CodePolicy 152

Change TypeReference update onlyno material clinical or coverage changes

Effective DateOct 1, 2026

Last ReviewSep 1, 2026

Next Review DateJun 1, 2027

Key ActionDocument the patient's specific medical problem, relevant findings, practitioner order, and how test results will directly guide management.

SourceLink

POLICY UPDATE CHANGES

The October 2026 interim update added the Noridian LCD L40324 and LCA A60361 to the policy references.

4General Medicare coverage requirements

83516

CPT code not covered for ALCAT or cytotoxic food testing

Rarely necessaryRepeat testing with the same antigen(s)

2Potentially medically necessary challenge categories

20Codes for miscellaneous tests not medically necessary

Medical Necessity and Coverage Criteria

General Medicare coverage requirements

A laboratory service, including allergy testing, must meet ALL of the following requirements for consideration of coverage:

General Medicare laboratory-service requirements

The service is not excluded from coverage by statute, regulation, a National Coverage Determination (NCD), or a Local Coverage Determination (LCD).
The service is ordered by a physician or qualified practitioner who is treating the beneficiary.
The service provides data that will be directly used in management of the beneficiary's specific medical problem.
The service is medically reasonable and necessary for diagnosis or treatment of an illness or injury, or to rule out or confirm a suspected diagnosis because the patient has signs and/or symptoms.

Individualized medical necessity and utilization

Medical necessity requires ALL of the following service-level considerations:

Appropriate performance and utilization

The service is appropriate for the member's condition.
The service is furnished for an appropriate duration and frequency and in accordance with accepted standards of medical practice for the condition.
The service is furnished in a setting appropriate to the member's medical needs and condition.
The service is ordered and furnished by qualified personnel.
The service meets, but does not exceed, the medical need.

Ophthalmic and direct nasal mucous membrane challenge tests

The following services may be considered medically necessary in some situations for Company Medicare Plan members:

Potentially medically necessary challenge testing

Ophthalmic mucous membrane challenge testing may be medically necessary when clinically indicated.
Direct nasal mucous membrane challenge testing may be medically necessary when clinically indicated.

CPT 83516 is not medically necessary and is not covered when billed to represent ALCAT or cytotoxic food testing.

The following miscellaneous allergy tests are identified as not medically necessary: bead-based epitope assays 0165U and 0178U; allergen-specific IgG testing 86001; qualitative multiallergen IgE screening 86005; leukocyte histamine release testing 86343; total serum IgE testing 82785; and allergen-specific IgE testing 86003 and 86008.

The listed miscellaneous allergy tests are considered not medically necessary, including specified laboratory allergy tests; percutaneous, intradermal, patch, and photo testing; ophthalmic and direct nasal mucous membrane tests; bronchial challenge testing; oral ingestion food challenge testing; and unlisted allergy or clinical immunologic services.

Repeat testing with the same antigen(s) is rarely medically necessary. Total testing should not exceed generally accepted professional standards. Although CMS medically unlikely edits establish the maximum number of units reasonably reported by the same provider for the same member on the same date of service, an MUE does not establish medical necessity. Every billed unit must be supported by documentation and justified as medically reasonable and necessary for the individual.

ALCAT, cytotoxic food testing, and the miscellaneous allergy tests identified in the policy's coding section are considered not medically necessary and are not covered.

Services listed under Coding for Miscellaneous Not Medically Necessary Tests are considered not medically necessary. These include allergen-specific IgG and IgE testing, leukocyte histamine release testing, total serum IgE testing, ALCAT or cytotoxic food testing, percutaneous and intradermal testing, patch and photo testing, ophthalmic and direct nasal mucous membrane tests, bronchial challenge testing, oral ingestion food challenge testing, and unlisted allergy or clinical immunologic services.

Allergy Testing Codes

Allergy testing codes referenced in Medicare coverage criteriaCPT

95060	Conjunctival or nasal challenge
95065	Conjunctival or nasal challenge
95070	Bronchial challenge
95004	Percutaneous allergy testing: scratch, prick, or puncture
95017	Percutaneous allergy testing: scratch, prick, or puncture
95018	Percutaneous allergy testing: scratch, prick, or puncture
95024	Intradermal allergy testing
95027	Intradermal allergy testing
95028	Intradermal allergy testing
95044	Skin patch testing

1–10 of 17

1/2

Coding for Miscellaneous Not Medically Necessary TestsCPTNot Covered

0165U	Peanut allergen-specific IgE and quantitative assessment of 64 epitopes using enzyme-linked immunosorbent assay (ELISA), blood, individual epitope results and interpretation; used for the VeriMAP Peanut Dx - Bead-based Epitope Assay test by AllerGenis.
0178U	Peanut allergen-specific quantitative assessment of multiple epitopes using enzyme-linked immunosorbent assay (ELISA), blood, report of minimum eliciting exposure for a clinical reaction; used for the VeriMAP Peanut Sensitivity - Bead-based Epitope Assay test by AllerGenis.
86001	Allergen specific IgG quantitative or semiquantitative, each allergen.
86005	Allergen specific IgE; qualitative, multiallergen screen (eg, disk, sponge, card).
86343	Leukocyte histamine release test (LHR).
82785	Gammaglobulin (immunoglobulin); IgE; total serum IgE testing (e.g., PRIST/RIST).
83516	Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method; includes allergen-specific IgE testing (e.g., RAST/MAST/FAST/ELISA/ImmunoCAP).
86003	Allergen specific IgE; quantitative or semiquantitative, crude allergen extract, each.
86008	Allergen specific IgE; quantitative or semiquantitative, recombinant or purified component, each.
86486	Skin test; unlisted antigen, each.

1–10 of 20

1/2

Documentation, Billing, and Denial Risks

Documentation Required

Medical-Necessity Documentation

Document the patient-specific medical necessity for allergy testing, including the problem, symptoms or suspected diagnosis, relevant history, physical examination, diagnoses, comorbidities, functional status, physician recommendations, clinical notes, and other supporting clinical information.

Explain how the results will be directly used to manage the patient's specific medical problem or to diagnose, treat, rule out, or confirm a suspected diagnosis.
Document the physician's clinical judgment and the patient's relevant exposure history, with a reasonable probability of exposure to the allergen in the patient's environment.

Documentation Required

Test Selection and Unit Documentation

Document the rationale for the specific type and quantity of allergy tests ordered for the individual patient. The record must connect the tests and reported units to the patient's history, physical findings, symptoms, diagnosis, and clinical judgment.

Support why each test type is relevant to the patient's clinical circumstances.

Medicare Allergy Testing Coverage

Medicare coverage of allergy testing requires the service to be medically reasonable and necessary to diagnose or treat illness or injury, or to confirm or rule out a suspected diagnosis based on signs and symptoms. The appropriate type and quantity of testing should reflect the member's history, physical findings, clinical judgment, and likely environmental allergen exposure.

Key Coverage Definitions

Medically reasonable and necessary

DefinitionA laboratory service is medically reasonable and necessary when it is appropriate for the patient's condition and medically needed to diagnose or treat illness or injury, or to confirm or rule out a suspected diagnosis based on signs or symptoms.

Duration and frequencyThe service must be furnished for an appropriate duration and frequency and must meet, but not exceed, the medical need.

Standards and settingThe service must be consistent with accepted standards of medical practice, provided in an appropriate setting, and ordered and furnished by qualified personnel.

Available alternativesThe service must be at least as beneficial as an existing and available medically appropriate alternative.

Medically unlikely edit (MUE)

Definition

Policy Summary

PayerProvidence Health Plan

PolicyAllergy Testing

Policy CodePolicy 152

Change TypeReference update onlyno material clinical or coverage changes

Effective DateOct 1, 2026

Last ReviewSep 1, 2026

Next Review DateJun 1, 2027

Key ActionDocument the patient's specific medical problem, relevant findings, practitioner order, and how test results will directly guide management.

SourceLink

On This Page

The service is at least as beneficial as an existing and available medically appropriate alternative.

The type and quantity of testing are relevant to the individual patient's history, physical findings, physician clinical judgment, and reasonable probability of exposure to the allergen in the patient's environment.

Repeat testing with the same antigen or antigens is rarely considered medically necessary.

The total number of tests does not exceed generally accepted standards of testing established by professional associations.

All reported units are justified, correctly coded, and supported by documentation showing that the services were rendered and were medically reasonable and necessary for the individual.

Justify all units reported and ensure documentation supports the services rendered, correct coding, and medical reasonableness and necessity.

Do not assume that the same tests or number of sensitivity tests are appropriate for every patient.

Denial Risk

Failure to Meet Medicare Coverage Requirements

Services may be denied when Medicare coverage requirements are not met. The test must not be excluded by statute, regulation, an NCD, or an LCD; must be ordered by a physician or qualified practitioner treating the beneficiary; must provide data directly used to manage the beneficiary's specific medical problem; and must be medically reasonable and necessary under Social Security Act §1862(a)(1)(A).

The service must be appropriate for the member's condition, including its duration, frequency, setting, personnel, and accepted standards of medical practice.
The service must meet but not exceed the medical need and be at least as beneficial as an existing and available medically appropriate alternative.
Medical-necessity determinations may consider coverage and benefit criteria, current standards of care, the member's unique medical history, physician recommendations, clinical notes, and plan medical-director involvement where appropriate.

Denial Risk

Excessive or Unsupported Testing

High-utilization allergy testing may be subject to medical review or audit, and testing can be denied when the type or quantity is excessive or clinically unsupported. CMS medically unlikely edits (MUEs) are maximum reportable units, not a guarantee of medical necessity, and all reported units must be justified for the individual patient.

Repeat testing with the same antigen(s) is rarely medically necessary.
Do not report the MUE maximum automatically for every visit or over the course of a year.
The total number of tests must not exceed generally accepted professional standards; apply utilization expectations such as those in Noridian LCD L40324 for applicable test types.

Denial Risk

Non-Covered Miscellaneous Allergy Tests

The following miscellaneous allergy tests are not covered or are considered not medically necessary under this policy. Claims for these services may be denied when billed for the non-covered testing described.

0165U — VeriMAP Peanut Dx bead-based epitope assay: peanut allergen-specific IgE and quantitative assessment of 64 epitopes using ELISA, blood, with individual epitope results and interpretation.
0178U — VeriMAP Peanut Sensitivity bead-based epitope assay: peanut allergen-specific quantitative assessment of multiple epitopes using ELISA, blood, with a report of minimum eliciting exposure for a clinical reaction.
86001 — Allergen-specific IgG quantitative or semiquantitative, each allergen.
86005 — Allergen-specific IgE qualitative multiallergen screen and leukocyte histamine release test.
86343 — Leukocyte histamine release test (LHR).
82785 — Total serum IgE testing, such as PRIST/RIST.
83516 — Immunoassay for analyte other than infectious-agent antibody or antigen; when billed for ALCAT, automated food, cytotoxic food, or another non-covered test, it is not medically necessary and not covered.
ALCAT, cytotoxic food testing, and other miscellaneous allergy tests listed in the policy are non-covered when submitted for the applicable non-covered service.

Billing Rule

Unlisted Code for Non-Covered Services

An unlisted code submitted for a non-covered service addressed by this policy will be denied as not covered. Unlisted codes are reviewed at the claim level for medical necessity, correct coding, and pricing.

For an unlisted code representing a potentially covered service addressed by this policy, prior authorization is recommended to help avoid post-service denial.
Use the applicable non-covered and prior-authorization lists and submit documentation supporting the service.

Billing Rule

Contract, Benefit, and Coding Edit Limitations

Claims remain subject to the applicable provider contract, member benefits, eligibility requirements, utilization audit, and coding edits regardless of whether a code appears on the policy list or has a payment amount in the Medicare Physician Fee Schedule database.

The policy's code list is provided as a courtesy and may not be all-inclusive; inclusion or omission does not imply or guarantee reimbursement or coverage.
CPT or HCPCS issuance and a Medicare payment or fee amount do not establish that a service is covered or medically reasonable and necessary.
Apply CMS National Correct Coding Initiative procedure-to-procedure bundling edits and medically unlikely edits (MUEs); this policy does not take precedence over NCCI or MUE requirements.
Some codes may not require routine medical-necessity review but remain subject to contracts, benefits, eligibility, and potential utilization audit.

The maximum number of units for a service that would reasonably be reported by the same provider for the same member on the same date of service.

Medical necessityAn MUE does not guarantee that the maximum number of units is medically necessary.

Individualized utilizationThe maximum number of units may not reflect the medical need of every patient at every visit or collectively over the course of an entire year.

Documentation requirementAll reported units must be justified, correctly coded, and supported by documentation showing that the services were medically reasonable and necessary for the individual.