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    v1.0.28
    OpenPayerPolicy UpdatesClinical/Medical PolicyProvidence Health Plan Allergy Testing Coverage | …
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    CurrentProvidence Health PlanPolicy 152

    Allergy Testing (Medicare)

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    Medicare medical policy describing coverage, medical necessity criteria parameters, and coding/billing guidance for allergy testing services for Providence Health Plan Medicare products.

    Policy Summary
    PayerProvidence Health Plan
    PolicyAllergy Testing (Medicare)
    Policy CodePolicy 152
    Change TypeNo material change
    Effective DateJul 1, 2026
    Last ReviewJul 1, 2026
    Next Review DateJun 1, 2027
    Key ActionObtain pre-service organization determination or prior authorization for unlisted codes to avoid post-service denial.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Medicare OnlyProduct applicability

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    152
    Policy ID
    83516Not medically necessary example
    1Unlisted codes reviewed
    2026-07-01Effective date

    Coverage and Medical Necessity Criteria

    Medically necessary when Company criteria are met

    Covered when Company medical policy criteria and Medicare requirements are met

    Medicare and Company criteria: Tests must not be excluded by statute/regulation/NCD/LCD; be ordered by a treating physician or qualified practitioner; provide data directly used in management of the beneficiary's specific medical problem; and be medically reasonable and necessary.

    Company will apply internal coverage criteria where Medicare criteria are not fully established; certain tests (e.g., ophthalmic mucous membrane challenge tests and direct nasal mucous membrane challenge tests) may be considered medically necessary in some situations.

    The policy identifies certain laboratory and proprietary assays that are considered not medically necessary when Company medical policy criteria are not met. Examples include ALCAT/cytotoxic food tests and other miscellaneous or unproven tests (for example, IgG/IgG4 testing, applied kinesiology, iridology, leukocyte histamine release testing). These tests will be treated as non-covered under the Company Medicare policy when the documented medical necessity criteria are not satisfied.

    When billed to represent an ALCAT or cytotoxic food test, CPT 83516 is considered not medically necessary and not covered under this policy.

    If an unlisted code is submitted for services that are non-covered by this policy, the claim will be denied as not covered. Providers are advised that all unlisted codes are reviewed at the claim level for medical necessity, correct coding, and pricing.

    Billing CPT 83516 specifically to represent an ALCAT/cytotoxic food testing method is considered not medically necessary and will be denied when used for a non-covered test under this policy.

    In short: billing CPT 83516 for ALCAT or cytotoxic food testing is not medically necessary and not covered.

    See the CODING section for the grouped list of listed CPT/HCPCS codes (examples and miscellaneous) referenced throughout this policy; this table consolidates codes used for miscellaneous allergy tests, allergen-specific serologies, and skin/challenge procedures.

    CPT / HCPCS / Procedure Codes

    Miscellaneous Allergy Tests / Allergen-specific serologiesCPT
    0165UPeanut 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)
    0178UPeanut 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)
    86001Allergen specific IgG quantitative or semiquantitative, each allergen
    86005Allergen specific IgE; qualitative, multiallergen screen (eg, disk, sponge, card)
    82785Gammaglobulin (immunoglobulin); IgE
    83516Antigen Leukocyte Cellular Antibody (ALCAT) Automated Food Test or Cytotoxic Food Test This code is considered not medically necessary when used for a non-covered test in this policy
    86003Allergen specific IgE; quantitative or semiquantitative, crude allergen extract, each
    86008Allergen specific IgE; quantitative or semiquantitative, recombinant or purified component, each
    Skin tests, challenge tests, and related proceduresCPT
    86486Skin test; unlisted antigen, each (Miscellaneous Antigen Skin Tests)
    95004Percutaneous Test (Scratch, Prick, or Puncture Test) with allergenic extracts, immediate type reaction, including interpretation and report; specify number of tests
    95017Allergy testing, any combination of percutaneous and intracutaneous, sequential and incremental, with venoms, immediate type reaction, including interpretation and report; specify number of tests
    95018Allergy testing, any combination of percutaneous and intracutaneous, sequential and incremental, with drugs or biologicals, immediate type reaction, including interpretation and report; specify number of tests
    95024Intracutaneous (intradermal) tests with allergenic extracts, immediate type; specify number of tests
    95027Intracutaneous (intradermal) tests, sequential and incremental, with allergenic extracts for airborne allergens, immediate type reaction, including interpretation and report
    95028Intracutaneous (intradermal) tests with allergenic extracts, delayed type reaction, including reading; specify number of tests
    95044Skin Patch Test; Patch or application test(s) (specify number of tests)
    95052Photo Test; Photo patch test(s) (specify number of tests)
    95056Photo tests
    1–10 of 16
    1/2
    Listed CPT/HCPCS codes (examples and miscellaneous)mixed
    83516Antigen Leukocyte Cellular Antibody (ALCAT) Automated Food Test or Cytotoxic Food Test — considered not medically necessary when used for a non-covered test in this policy
    0165UPeanut allergen-specific IgE and quantitative assessment of 64 epitopes using ELISA, individual epitope results and interpretation (VeriMAP Peanut Dx - Bead-based Epitope Assay)
    0178UPeanut allergen-specific quantitative assessment of multiple epitopes using ELISA, blood, report of minimum eliciting exposure (VeriMAP Peanut Sensitivity - Bead-based Epitope Assay)
    86001Allergen specific IgG quantitative or semiquantitative, each allergen
    86005Allergen specific IgE; qualitative, multiallergen screen (eg, disk, sponge, card)
    82785Gammaglobulin (immunoglobulin); IgE
    86003Allergen specific IgE; quantitative or semiquantitative, crude allergen extract, each
    86008Allergen specific IgE; quantitative or semiquantitative, recombinant or purified component, each
    86486Skin test; unlisted antigen, each
    95004Percutaneous Test (Scratch, Prick, or Puncture Test) with allergenic extracts, immediate type reaction, including interpretation and report
    1–10 of 14
    1/2

    What Providers Must Do

    Prior Authorization

    Request pre-service determination when coverage is uncertain

    When coverage is uncertain, submit a pre-service organization determination (prior authorization) or review the member Evidence of Coverage (EOC) to allow individualized determination of medical necessity before performing testing.

    Prior Authorization

    Obtain prior authorization for unlisted codes

    When using an unlisted code (e.g., 95199) for a potentially covered service, obtain prior authorization to avoid post-service denial since unlisted codes are reviewed at the claim level.

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

    Policy Background and Medicare Requirements

    Medicare coverage requires that tests not be excluded by statute, regulation, or local/national coverage determinations and that services be medically reasonable and necessary. Tests must be ordered by a treating physician or qualified practitioner and provide data that will be directly used in the management of the beneficiary's specific medical problem. Company determinations align with these Medicare requirements and apply the Company’s internal coverage criteria when Medicare criteria are not fully established.

    Definitions

    Medically reasonable and necessary — definition and attributes
    DefinitionService that is appropriate for diagnosis or treatment, ordered by qualified personnel, furnished in accordance with accepted standards of medical practice, and likely to affect management of the beneficiary's specific medical problem.
    Medicare requirementsNot excluded by statute/regulation/NCD/LCD; ordered by a treating physician or qualified practitioner; provides data directly used to manage the beneficiary's specific medical problem; considered medically reasonable and necessary under Social Security Act §1862(a)(1)(A).
    Appropriateness criteriaAppropriate in duration, frequency, and setting; ordered and furnished by qualified personnel; meets but does not exceed medical need; at least as beneficial as available medically appropriate alternatives.
    Patient-centered testingType and quantity of tests must be relevant to the individual based on history, physical findings, and clinician judgment with reasonable probability of exposure to the allergen.
    Use of internal Company criteriaWhen Medicare statutes/regulations/NCDs/LCDs do not fully establish coverage, the Company may apply publicly accessible internal coverage criteria based on current evidence and guidelines.
    Policy Summary
    PayerProvidence Health Plan
    PolicyAllergy Testing (Medicare)
    Policy CodePolicy 152
    Change TypeNo material change
    Effective DateJul 1, 2026
    Last ReviewJul 1, 2026
    Next Review DateJun 1, 2027
    Key ActionObtain pre-service organization determination or prior authorization for unlisted codes to avoid post-service denial.
    SourceLink
    On This Page
    Coverage and Medical Necessity CriteriaCPT / HCPCS / Procedure CodesWhat Providers Must DoPolicy Background and Medicare RequirementsDefinitions
    Step Therapy

    Use clinical justification to guide test selection

    Order tests only when the type and quantity are relevant to the individual patient based on history, physical findings, and a reasonable probability of exposure; clinical judgment should guide test selection and sequencing.

    • The type and quantity of tests must be relevant to the individual patient based on history and physical findings.
    • Clinical judgment should guide testing selection and sequencing with reasonable probability of exposure to the allergen.
    Note
    Documentation Required

    Ordering and documentation requirements

    Ensure tests are ordered by the treating physician or a qualified practitioner and document that results will be directly used in management of the beneficiary's specific medical problem; documentation must justify units, frequency, and medical necessity.

    • Tests must be ordered by a physician or qualified practitioner who is treating the beneficiary.
    • Documentation must show results will be directly used in managing the beneficiary's specific medical problem and must justify units, frequency, and medical necessity.
    Prior Authorization

    Unlisted codes are reviewed — prior authorization recommended

    All unlisted codes will be reviewed at the claim level for medical necessity, correct coding, and pricing; prior authorization is recommended when submitting unlisted codes for potentially covered services to avoid post-service denial.

    • 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 submitted for potentially covered services.
    Denial Risk

    Denial risk for unjustified repeat or high-volume testing

    Repeat testing with the same antigen(s) is rarely considered medically necessary; lack of documentation to justify the number of units or frequency may lead to medical review or denial.

    • High utilization testing may be subject to medical review or audit.
    • All units reported on any claim must be justified and supported by documentation that services were medically reasonable and necessary.
    Denial Risk

    Unlisted codes for non-covered services will be denied

    If an unlisted code is submitted for services that are non-covered under this policy, the claim will be denied as not covered.

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

    Do not bill 83516 for ALCAT/cytotoxic food testing

    Billing CPT code 83516 to represent ALCAT or cytotoxic food testing is considered not medically necessary and will be denied.

    • When CPT code 83516 is billed to represent ALCAT or cytotoxic food testing, it is considered not medically necessary and not covered per this policy.