Clinical Policy: Allergy Testing and Therapy

Reference Number: CP.MP.100
Date of Last Revision: 09/25

[Coding Implications](Coding Implications)
[Revision Log](Revision Log)

See [Important Reminder](Important Reminder) at the end of this policy for important regulatory and legal information.

Description

Allergy testing is performed to determine immunologic sensitivity or reaction to antigens for the purpose of identifying the cause of the allergic state. This policy addresses immediate, or immunoglobulin E (IgE)-mediated, hypersensitivity and delayed, or cell-mediated, hypersensitivity.¹,¹² Allergen immunotherapy is the repeated administration of specific allergens to patients with IgE-mediated conditions for the purpose of providing protection against the allergic symptoms and inflammatory reactions associated with exposure to these allergens.⁹

Please note: unit limitations for allergy testing and treatment are based on state-specific guidelines (defined in the provider fee schedule). In the absence of state-specific rules, the CMS Medicaid/Medicare NCCI MUE limitations are applied.

Policy/Criteria

I. It is the policy of health plans affiliated with Centene Corporation® that allergy testing is medically necessary for members/enrollees with clinically significant allergic symptoms and the following indications:
A. As part of a complete diagnostic evaluation by a licensed practitioner acting within their scope of practice to perform allergy and immunology services;
B. Antigens include only those that are reasonably possible for the member/enrollee to be exposed to;
C. Chosen tests are as follows:

1. Percutaneous testing (scratch, puncture, prick) (CPT 95004, 95017, 95018) for offending allergens such as pollen, molds, mites, dust, feathers, animal fur or dander, venoms, foods, or drugs;
2. Intracutaneous (intradermal), sequential and incremental testing (CPT 95024, 95027, 95028) when percutaneous tests are negative;
3. Skin endpoint titration (95027) for determining the starting dose for immunotherapy for member/enrollee highly allergic to an inhalant allergen or hymenoptera venom allergy (insect stings);
4. In vitro testing (CPT 86003, 86005, 86008);
5. Patch testing (CPT 95044);
6. If photo patch test(s) (CPT 95052) are performed (same antigen/same session) with patch or application test(s) (CPT 95044), only the photo patch tests should be reported;
7. If photo tests (CPT 95056) are performed with patch or application test(s) (CPT 95044), only the photo tests should be reported.
8. Ingestion (oral) challenge testing (CPT 95076, 95079) for food, drugs, or other substances if skin testing is negative or allergy diagnosis is uncertain.

Page 1 of 20

CLINICAL POLICY

Allergy Testing and Therapy

II. It is the policy of health plans affiliated with Centene that allergy immunotherapy administered in a medical facility is medically necessary when meeting all of the following indications:
A. Positive skin test or serologic evidence of an IgE-mediated antibody for allergens which cause any of the following:

1. Allergic (extrinsic) asthma;
2. Dust mite atopic dermatitis;
3. Hymenoptera (bees, hornets, wasps, fire ants) allergic reactions;
4. Mold-induced allergic rhinitis;
5. Perennial allergic rhinitis;
6. Seasonal allergic rhinitis or conjunctivitis;
   B. Symptoms of allergic rhinitis or asthma after natural exposure to the allergen; or a life-threatening allergy to insect stings (bees, hornets, wasps, and fire ants);
   C. Avoidance or pharmacologic therapy does not control allergic symptoms or member/enrollee has unacceptable side effects with pharmacologic therapy;
   D. If rapid desensitization/rush immunotherapy is requested, it is only medically necessary for medication or hymenoptera (bees, hornets, wasps, fire ants) sensitivities;
   E. Antigens are prepared by the clinical staff directly overseen by the physician who examined the patient and who has training and expertise in allergen immunotherapy (i.e., allergist, immunologist, pulmonologist or otolaryngologist. Other specialties must provide evidence of expertise and training consistent with the American College of Allergy, Asthma, and Immunology (ACAAI) Allergen Immunotherapy Extract Preparation Instructional Guide).³*

Note: Please see background section for information on training requirements for immunotherapy preparation and administration.

Note: For FDA-approved sublingual immunotherapy, please refer to applicable pharmacy policy for coverage criteria.

III. It is the policy of health plans affiliated with Centene that the following are considered not medically necessary because safety or effectiveness have not been established:
A. Testing for the following antigens:

1. Newsprint;
2. Tobacco smoke;
3. Dandelion;
4. Orris root;
5. Phenol;
6. Alcohol;
7. Sugar;
8. Yeast;
9. Grain mill dust;
10. Soybean dust (except when the member/enrollee has a known exposure to soybean dust such as a food processing plant);
11. Wool (unless patient has history of continuous exposure to sheep or unprocessed wool);

Page 2 of 20

CLINICAL POLICY

Allergy Testing and Therapy

12. Marigold;
13. Honeysuckle;
14. Fiberglass;
15. Green tea;
16. Chalk;
17. Cornstarch;
18. Cotton;
19. Formaldehyde;
20. Smog.

B. The following tests for the evaluation of allergic reactions:

1. Antigen leukocyte cellular antibody (ALCAT) automated food allergy testing;
2. Applied kinesiology or Nambudripad’s allergy elimination test (NAET (i.e., muscle strength testing or measurement after allergen ingestion);
3. Anti-Fc epsilon receptor antibodies testing;
4. Anti-IgE receptor antibody testing;
5. Blood, urine, or stool micro-nutrient assessments;
6. Candidiasis test;
7. Chemical analysis of body tissues (e.g., hair);
8. Chlorinated pesticides (serum);
9. Chronic urticarial index testing;
10. Clifford materials reactivity testing;
11. Complement (total or components);
12. Complement antigen testing;
13. C-reactive protein;
14. Cytokine and cytokine receptor assay;
15. Cytotoxic testing for food, environmental or clinical ecological allergy testing (Bryans Test, ACT);
16. Electrodermal testing or electro-acupuncture;
17. Electromagnetic sensitivity syndrome/disorder (allergy to electricity, electro-sensitivity, electrohypersensitivity, and hypersensitivity to electricity);
18. Environmental cultures and chemicals;
19. Eosinophil cationic protein (ECP) test;
20. ELISA/Act qualitative antibody testing;
21. Food immune complex assay (FICA);
22. General immune system assessments;
23. Immune complex assay;
24. Ingestion challenge food testing for diagnosing rheumatoid arthritis, depression, or respiratory disorders not associated with anaphylaxis or similar systemic reactions;
25. In vitro metal allergy testing;
26. Iridology;
27. Leukocyte histamine release test (LHRT)/basophil histamine release test;
28. Live Cell Analysis;
29. Lymphocyte function assay;
30. Lymphocytes (B or T subsets);

Page 3 of 20

CLINICAL POLICY

Allergy Testing and Therapy

31. Lymphocyte Response Assay (LRA) by ELISA/ACT and Lymphocyte Mitogen Response Assays (LMRA) by ELISA/Act;
32. Mediator release test (MRT);
33. Metabolic assessments;
34. Ophthalmic mucus membrane tests/conjunctival challenge test;
35. Prausnitz-Kustner (P-K testing) passive cutaneous transfer test;
36. Provocative and neutralization testing and neutralization therapy (sublingual, intracutaneous and subcutaneous) also referred to as the Rinkel Test, for food allergies, inhalants, and environmental chemicals because available evidence does not show these tests and therapies are effective;
37. Provocative nasal test;
38. Pulse test (pulse response test, reaginic pulse test);
39. Qualification of nutritional assessments;
40. Rebück skin window test;
41. Secretory IgA (salvia);
42. Sage Complement Antigen Test;
43. Testing for multiple chemical sensitivity syndrome (a.k.a., idiopathic environmental intolerance [IEI], clinical ecological illness, clinical ecology, environmental illness, chemical AIDS, environmental/chemical hypersensitivity disease, total allergy syndrome, cerebral allergy, 20th century disease);
44. Testing of specific immunoglobulin G (IgG) (e.g., by Radioallergosorbent [RAST] or Enzyme-linked immunosorbent assay [ELISA]);
45. Testing of total serum IgG, immunoglobulin A (IgA) and immunoglobulin M (IgM);
46. Testing for venom blocking antibodies;
47. VeriMAP Peanut Diagnostic™ (bead-based epitope assay).

C. The following services in relation to allergy testing and immunotherapy:

1. Desensitization with commercially available extracts of poison ivy, poison oak, or poison sumac;
2. Desensitization for hymenoptera sensitivity using whole body extracts, with the exception of venom extracts and fire ant extracts;
3. Desensitization with bacterial vaccine (BAC: bacterial, antigen complex, streptococcus vaccine, staphylo/strepto vaccine, serobacterin, staphylococcus phage lysate);
4. Food allergenic extract immunotherapy;
5. Intracutaneous desensitization (Rinkel Injection Therapy, RIT);
6. Neutralization therapy (intradermal and subcutaneous);
7. Repository emulsion therapy;
8. Non-FDA approved sublingual immunotherapy;
9. Urine auto-injection (autogenous urine immunotherapy);
10. Allergen immunotherapy for the management of skin and mucous membrane disease such as urticaria and Candida vulvovaginitis;
11. Home administration of allergy immunotherapy;
12. Ingestion challenge food testing performed by the patient in the home;
13. Intradermal testing for food allergies;

Page 4 of 20

CLINICAL POLICY

Allergy Testing and Therapy

14. Food allergen testing for patients who present with gastrointestinal symptoms suggestive of food intolerance;
15. Rush immunotherapy for inhalant allergens.

Limitations

Allergy Testing⁴,⁵,⁶

• Retesting with the same antigen(s) should rarely be necessary within a three-year period. Exceptions include children and adolescents with documented food allergy requiring follow up and young children with negative skin tests or older children and adults with negative skin tests in the face of persistent symptoms;
• Routine repetition of skin tests is not indicated (e.g., annually);
• Measurements of total IgE levels (CPT code 82785-Gammaglobulin [immunoglobulin]; IgE) are not appropriate for most general allergies for the purpose of identifying the cause of the allergic state. Total serum IgE levels should not be billed unless evidence exists for allergic bronchopulmonary Aspergillosis (ABPA), select immunodeficiencies, such as the syndrome of hyper-IgE, eczematous dermatitis, atopic dermatitis in children and recurrent pyogenic infections, or in the evaluation for omalizumab therapy;

• Serial, repeat testing of total IgE will be subject to medical review.

Background

Allergy Testing

An allergy is the exaggerated sensitivity, or hypersensitivity, to an ordinarily harmless substance, or an allergen, that is either inhaled, ingested, injected, or comes in contact with the skin or eye.⁷,²¹ Allergic or hypersensitivity disorders may be manifested by generalized systemic or localized reactions on any part of the body. These reactions may be acute, subacute, or chronic, immediate or delayed and may be caused by a variety of offending agents (e.g., pollen, molds, mites, dust, feathers, animal fur or dander, venoms, foods, drugs).⁷ Allergy testing is performed to determine a patient’s immunologic sensitivity or reaction to particular allergens for the purpose of identifying the cause of the allergic state.⁷,⁸

Page 5 of 20

CLINICAL POLICY

Allergy Testing and Therapy

Allergy testing must be a part of a complete diagnostic evaluation by a physician with specialized training in allergy and immunotherapy. A complete medical and immunologic history and appropriate physical examination must be done prior to performing diagnostic testing. The testing must be performed based on this history and a physical exam, which documents that the antigens being used for testing exist with a reasonable probability of exposure in the patient’s environment. The number of tests performed must be judicious and related to the history, physical findings, and clinical judgment specific to each individual.¹

In vivo immunologic tests have shown to be reliable and valid diagnostic tools and include skin tests with standardized allergenic extracts by prick/puncture (percutaneous) and intradermal (intracutaneous) techniques, photo and patch testing, inhalation bronchial challenge testing, and ingestion challenge testing.

Percutaneous testing remains the test of choice in most clinical situations where immediate, or immunoglobulin E (IgE)-mediated, hypersensitivity reactions are suspected.¹,⁷ Although percutaneous tests require medical supervision since a small but significant risk of anaphylaxis exists, these tests are quick, safe, and cost-effective.¹

Intracutaneous or intradermal tests are usually performed when increased sensitivity is needed when percutaneous tests (CPT codes 95004, 95017, 95018) are negative, and there is still a strong suspicion of allergen sensitivity. For intradermal testing, the clinician should narrow the area of investigation so that the minimal number of skin tests necessary for diagnosis is performed. Intradermal testing is appropriate when IgE-mediated reactions occur to inhalants, hymenoptera (insect stings), and specific drugs, such as penicillins and macromolecular agents.⁵ The usual testing program may include two concentrations of an extract: a weaker concentration and a stronger concentration. It would not be expected that three or more concentrations of one extract would be necessary. Skin end-point dilution testing is a variant of intradermal testing that analyzes the highest dilution of a substance that produces a reaction and may be used to determine the starting dose(s) of allergen immunotherapy.¹

Delayed hypersensitivity skin testing measures the presence of activated T cells that recognize a certain substance. It has been commonly used in three ways: anergy testing, testing for infection with intracellular pathogens, and testing for sensitivity to contact allergens. Accurate testing for contact allergy requires careful attention to technique, and limitation of testing to the specific allergens known to be associated with a contact reaction.¹

Other skin tests include photo testing, patch testing, and photo patch testing. Photo testing is skin irradiation with a specific range of ultraviolet light. Photo tests are performed for the evaluation of photosensitivity disorders. Patch testing is indicated to evaluate a nonspecific dermatitis, allergic contact dermatitis, pruritus, and other dermatitis to determine the causative antigen. Photo patch testing uses two patches, with one of them being irradiated with ultraviolet light halfway through the occlusive period. It is indicated to evaluate unique allergies resulting from light exposure.¹,⁸

Page 6 of 20

CLINICAL POLICY

Allergy Testing and Therapy

Inhalation bronchial challenge testing involves the inhalation of agents that can trigger respiratory responses. The agents include drugs that cause airway constriction, antigens, and chemical sensitizers usually related to occupational breathing problems. Generally, three measures of each determination (e.g., spirometry, prolonged post exposure evaluation of bronchospasm) are performed. The best of the three is accepted and represents one unit of service. A unit is defined as each set of three measurements.¹

The ingestion challenge test involves the administration of sequentially or incrementally larger doses of the test item. The test items may include food or antibiotics. The service is allowed once per patient encounter, regardless of the number of items tested, and includes evaluation of the patient’s response to the test items.¹

Quantitative or semi-quantitative in vitro allergen specific IgE testing includes radioallergosorbent test (RAST), multiple radioallergosorbent tests (MAST), fluorescent allergosorbent test (FAST), enzyme-linked immunosorbent assay (ELISA) and ImmunoCAP. These tests detect specific IgE antibodies in the patient’s blood serum and are performed when skin testing is not possible or not reliable. Examples of indications for in vitro testing (CPT codes 86003, 86005 and 86008) include:

• Severe dermatographism, ichthyosis or generalized eczema;
• Increased risk for anaphylactic response to skin testing based on clinical history (e.g., when an unusual allergen is not available as a licensed skin test extract);
• Inability to discontinue long-acting antihistamines, tricyclic antidepressants, or medications that may put the patient at undue risk if they are discontinued long enough to perform skin tests;
• Those with mental or physical impairments who are uncooperative;
• History is highly suggestive of an allergy and skin testing is negative or equivocal; or
• Evaluation of cross-reactivity between insect venoms.¹

Total serum IgE concentration testing is not indicated in all allergic patients but should be reserved for those patients suspected of having allergic bronchopulmonary aspergillosis, immune deficiency disease (e.g., Wiskott-Aldrich syndrome, hyper-IgE staphylococcal abscess syndrome), IgE myeloma or pemphigoid, or for consideration of Xolair (omalizumab) administration in patients with moderate to severe asthma.²⁰

Allergen Immunotherapy⁹,²²

Immunotherapy is indicated for patients who show evidence of specific IgE antibodies to clinically relevant allergens and whose allergic symptoms warrant the time and risk of allergen immunotherapy. This includes those with allergic asthma, allergic conjunctivitis, allergic rhinitis, or stinging insect hypersensitivity depending on the results of allergy testing (immediate hypersensitivity skin tests or in vitro tests for specific IgE). Allergen immunotherapy is also effective for pollen, mold, animal allergens, cockroach, and dust mite. Initiating allergen immunotherapy may depend on the degree to which symptoms can be reduced by medication, the amount and type of medication required to control symptoms, and whether appropriate avoidance is possible.

Page 7 of 20

CLINICAL POLICY

Allergy Testing and Therapy

There is limited data showing effectiveness in atopic dermatitis when this condition is associated with aeroallergen sensitivity. Immunotherapy should not be given to patients with negative results for specific IgE antibodies or those with positive test results for specific IgE antibodies that do not correlate with suspected triggers, clinical symptoms, or exposure.

Venom immunotherapy is indicated for patients who have anaphylaxis after an insect sting and a positive skin test or other documented IgE sensitivity to specific insect venom. Patients with delayed systemic reactions with symptoms of anaphylaxis or serum sickness and with a positive skin test or presence of venom specific IgE by in vitro testing are also recommended for treatment.

Rapid desensitization is indicated in cases of allergy to insulin, penicillin, and horse serum, as well as sulfonamides, cephalosporins and other commonly used drugs. In patients with a positive history of reaction and with documented skin test reactivity, every effort should be made to avoid the use of these substances. When circumstances require the use of one of these substances, the patient will have to be desensitized. Full-dose therapy should be initiated immediately after reactions (treated and controlled), requiring strict physician monitoring in a setting with continuous monitoring of vital signs and cardio-respiratory status. In most cases, this can be performed in a physician’s office if a physician trained to treat anaphylaxis is physically present for the entire duration. In cases where the initial reaction was severe, desensitization should be performed in the ambulatory care department of a hospital.

Desensitization may need to be repeated if future circumstances require an additional course of the offending allergen. Rapid desensitization in the form of rush immunotherapy may also be appropriate for hymenoptera venom (bees, hornets, wasps, fire ants).

Sublingual Immunotherapy¹⁰

The American Academy of Allergy, Asthma & Immunology (AAAAI) recommends only FDA-approved sublingual immunotherapy (SLIT) products for the treatment of allergic rhinitis/rhinoconjunctivitis and not for any other related or unrelated condition. Off-label use of aqueous SLIT extracts or any other non-FDA approved SLIT formulation is not endorsed.

Treatment Schedules⁹

The starting dose of an allergenic extract and the progression of the dose must be individualized for each patient. The immunotherapy build-up schedule entails administration of gradually increasing doses during a period of approximately 14 to 28 weeks. In conventional schedules, a single dose increase is given on each visit, and the visit frequency can vary from one to three times a week. Accelerated schedules such as rush or cluster immunotherapy entail administration of several injections at increasing doses on a single visit. Accelerated schedules offer the advantage of achieving the therapeutic dose earlier but might be associated with increased risk of systemic reaction in some patients.

Length of Therapy⁹

The duration of all forms of immunotherapy must be individualized. A presumption of failure can be made when, after 12 to 24 months of therapy, a person does not experience a noticeable

Page 8 of 20

CLINICAL POLICY

Allergy Testing and Therapy

decrease of symptoms, an increase in tolerance to the offending allergen and a reduction in medication usage. Treatment will not be reimbursed after a two-year period when there is no apparent clinical benefit.

Immunotherapy Preparation and Administration³,²²,²³

The training of personnel involved in preparation and/or administration of allergen immunotherapy extracts is a critical requirement for safety and efficacy. It is a technical skill that requires specific training and a high level of attention to detail.

The suggested qualifications of extract preparation personnel based on the AAAAI Practice Parameter on Allergen Immunotherapy and The United States Pharmacopeial Convention (USP) Chapter 797 Pharmaceutical Compounding- Sterile Preparations standards include the following:

• Demonstrate understanding of appropriate hand hygiene, garbing, surface disinfection, aseptic technique, achieving and/or maintaining sterility, calculating/measuring/mixing, use of equipment and documentation.
• Pass a written test on aseptic technique and extract preparation.
• Annually pass a media-fill or equivalent test verifying use of aseptic technique.
• Annually pass a gloved fingertip-thumb sampling test verifying hand sterility after passing three initial tests.
• Be re-instructed and re-evaluated if failing the written test, media-fill test, or gloved fingertip-thumb sampling test.

Additionally, allergist offices must keep and maintain documentation of the standard operating procedure describing all aspects of the compounding process; records of training, assessment results, evaluations, and qualifications for all compounding personnel, including any corrective actions following assessments and evaluations; certification reports of the primary engineering control, if used, including corrective actions for any failures; temperature logs for the refrigerator(s); compounding records for individual allergenic extract prescription sets; information related to complaints and adverse events; and investigations and corrective actions.

Although allergen immunotherapy is generally well tolerated, anaphylaxis is a major risk. Therefore, allergen immunotherapy should be administered under the supervision of an appropriately trained physician who can recognize early symptoms and signs of anaphylaxis and administer emergency medications when necessary. In addition, immunotherapy should be administered only in facilities equipped to treat anaphylaxis.

Evaluation and management codes are separately reimbursable on the same day as allergen immunotherapy only when a significant, separately identifiable service is performed.

Coding Implications

This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2024, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage.

Page 9 of 20

CLINICAL POLICY

Allergy Testing and Therapy

Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

CPT Code Table 1: Procedure codes considered medically necessary when diagnosis code requirements are met per the ICD-10 tables.

Page 10 of 20

CLINICAL POLICY
Allergy Testing and Therapy

CPT Code Table 2: Procedure codes considered not medically necessary

ICD-10-CM Code Table 1: Diagnoses that support medical necessity for CPT codes 86003, 86005, 86008, 95004, 95017, 95018, 95024, 95027, 95028

CLINICAL POLICY
Allergy Testing and Therapy

ICD-10-CM Code Table 2: Diagnoses that support medical necessity for CPT code 95044

CLINICAL POLICY
Allergy Testing and Therapy

ICD-10-CM Code Table 3: Diagnoses that support medical necessity for CPT codes 95052, 95056

ICD-10-CM Code Table 4: Diagnoses that support medical necessity for CPT codes 95076, 95079

ICD-10-CM Code Table 5: Diagnoses that support medical necessity for CPT codes 95115, 95117, 95144, 95145, 95146, 95147, 95148, 95149, 95165, 95170, and 95199

CLINICAL POLICY
Allergy Testing and Therapy

ICD-10-CM Code Table 6: Diagnoses that support medical necessity for CPT code 95180

ICD-10-CM Code Table 7: Diagnoses that do not support medical necessity for CPT codes 86160, 86161 and 86162

CLINICAL POLICY
Allergy Testing and Therapy

CLINICAL POLICY
Allergy Testing and Therapy

CLINICAL POLICY
Allergy Testing and Therapy