Prior authorization for inhalation bronchial challenge

Inhalation bronchial challenge testing is considered medically appropriate when used for provocative testing with histamine, methacholine, or similar compounds; however, do not use inhalation challenge to evaluate common allergens (dust, ragweed, or other common allergens) because skin testing is appropriate for those situations.

• Prior authorization may be required per product rules — confirm with payer.

Allergen-specific IgE — limited coverage circumstances

Allergen-specific IgE testing is covered only in restricted clinical circumstances such as suspected latex allergy, suspected insect sting allergy with prior negative skin testing, or suspected penicillin allergy (and other listed situations where skin testing is not possible or appropriate). Order IgE testing only when one of these specified indications applies.

• Examples of allowed circumstances are: suspected latex allergy; suspected insect sting allergy with prior negative skin testing; suspected penicillin allergy.

Confirm coverage/authorization with payer

Confirm coverage and authorization with the member’s payer before ordering tests — codes listed in the policy may not be covered under all circumstances and the code list may not be all inclusive.

• Payer product rules and prior authorization requirements must be followed.
• Code lists may change (AMA/CMS updates).

Prior authorization is product‑dependent

Prior authorization requirements vary by product; when a product covers a service and requires medical policy criteria, follow the product’s prior authorization rules.

• If a product does not cover a service, medical policy criteria do not apply.
• If a commercial/Medicaid/Medicare product covers the service, medical policy criteria apply.

Step therapy — none specified

There are no specific step therapy requirements specified in this policy section.

Document test type and clinical indication

Document the specific test performed (for example: percutaneous, intracutaneous/intradermal, patch/photo patch/photo test, inhalation challenge, ingestion challenge, or IgE/gammaglobulin) and record the clinical indication in the medical record.

• Include test interpretation and provider report when applicable.

Intracutaneous (serial endpoint) test documentation

For intracutaneous (serial endpoint) testing, specify the number of tests performed (each sequential test = 1 unit), and include test interpretation and the provider report in the record.

• Charge each sequential intracutaneous test as one unit and document endpoint results.

CLIA requirement for laboratory‑developed tests

Laboratory-developed tests must meet CLIA regulatory standards and be performed by laboratories licensed by CLIA for high‑complexity testing.

• Ensure ordering/performing laboratory is CLIA‑licensed for high-complexity tests.

Document product coverage and follow product‑specific rules

When a product covers a diagnostic or testing product, document product coverage and applicability per the product’s rules; if the product covers the service and requires medical policy criteria, follow those criteria.

• If a product does not cover a service, the medical policy criteria do not apply.

Denial risk: inhalation challenge for common allergens

Do not submit claims for inhalation bronchial challenge when dust, ragweed, or other common allergens are the suspected cause — such use is not medically appropriate and is at risk for denial.

• Use skin testing instead when common allergens are suspected.

Denial risk: investigational tests

Claims for tests designated investigational (examples include allergen-specific IgG when criteria are not met; leukocyte histamine release test; ophthalmic or direct nasal mucous membrane tests; peanut multi‑epitope ELISA; cytotoxicity/provocative tests) are at risk for denial.

• Do not order or bill investigational tests unless covered by the member’s product or prior authorized.
• Examples of investigational tests are listed in the policy and include ELISA multi‑epitope peanut assays.

Risk: experimental/investigational codes may be denied

CPT and proprietary codes marked as (E/I) are designated experimental/investigational (for example, 0165U, 0178U, 95060 (E/I), 95065 (E/I), 86001 (E/I)) and may not be covered; confirm coverage before ordering or billing.

• Do not assume coverage for codes flagged E/I — obtain payer confirmation or prior authorization.

Contract‑dependent coverage can affect authorization

Coverage of services is contract dependent; if a member’s product does not cover a service, medical policy criteria do not apply and the claim may be denied.

• Verify product-level coverage prior to testing.