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Medical Policy Leukocyte Histamine Release Test Table of Contents
• Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 589 BCBSA Reference Number: 2.04.42A (For Plan internal use only) NCD/LCD: N/A Related Policies
None Policy
Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

The leukocyte histamine release test (LHRT) is INVESTIGATIONAL as a technique for the diagnosis and management of allergic disorders.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) This is not a covered service. Commercial PPO and Indemnity This is not a covered service. Medicare HMO BlueSM This is not a covered service. Medicare PPO BlueSM This is not a covered service.

CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

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Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable. CPT Codes CPT codes:

Code Description 86343 Leukocyte histamine release test (LHR)

Description The leukocyte histamine release test (LHRT) is designed to provide an in vitro correlate to an in vivo allergic response (i.e., skin prick testing). An allergen is added to the peripheral blood leukocytes of the individual being tested and the in vitro release of histamine from basophils in response to exposure to the allergen is measured. Histamine is normally released as a consequence of the interaction of allergen with cell-bound IgE antibodies.
In contrast, the RAST test (radioallergosorbent test) attempts to correlate the presence of allergy to serum levels of antigen-specific IgE as an index of allergic reactivity. Initially, measurements of histamine release required isolation of leukocytes from whole blood followed by the isolation of the released histamine; the laboratory techniques were difficult and time consuming and thus LHRT was primarily used as a research tool only.
Recently, a special type of glass fiber has been developed that binds histamine with high affinity and selectivity. These glass fibers can be used as a "solid phase" to absorb the histamine that is released directly into the blood. The recent commercial availability of simplified and automated methods of laboratory analysis (i.e., both ELISA and radioimmunoassays) have renewed interest in the clinical applications of LHRT in the evaluation of food, inhalant, and drug allergies. Summary Overall, the studies published on this test are potentially prone to spectrum bias, referral bias, and ascertainment bias, and are not sufficient to permit conclusions on the diagnostic accuracy of LHRT. It has been suggested that LHRT may be a valuable test in those patients with discordant results of skin prick testing and RAST testing, but studies focusing on this subgroup of patients were not identified in a literature search. Thus, this testing is considered investigational.
Policy History Date Action 11/2011- 4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates.
No changes to policy statements.
3/2011 Reviewed - Medical Policy Group - Allergy and ENT/Otolaryngology. No changes to policy statements. 3/2010 Reviewed - Medical Policy Group - Allergy and ENT/Otolaryngology. No changes to policy statements. 3/2009 Reviewed - Medical Policy Group - Allergy and ENT/Otolaryngology. No changes to policy statements. 3/2008 Reviewed - Medical Policy Group - Allergy and ENT/Otolaryngology. No changes to policy statements. 3/2007 Reviewed - Medical Policy Group - Allergy and ENT/Otolaryngology. No changes to policy statements. 3/2007 Annual policy review. No changes to policy statements.

Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use

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Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

References

1. Griese M, Kusenbach G, Reinhardt D. Histamine release test in comparison to standard tests in diagnosis of childhood allergic asthma. Ann Allergy 1990; 65(1):46-51.
2. Skov PS, Mosbech M, Norn S et al. Sensitive glass microfibre-based histamine analysis for allergy testing in washed blood cells. Results compared with conventional leukocyte histamine release assay. Allergy 1985; 40(3):213-8.
3. Ostergaard PA, Ebbensen F, Nolte H et al. Basophil histamine release in the diagnosis of house dust mite and dander allergy of asthmatic children. Comparison between prick test, RAST, basophil histamine release and bronchial provocation. Allergy 1990; 45(3):231-5.
4. Kleine-Tebbe J, Werfel S, Roedsgaard D et al. Comparison of fiberglass-based histamine assay with a conventional automated fluorometric histamine assay, case history, skin prick test, and specific serum IgE in patients with milk and egg allergic reactions. Allergy 1993; 48(1):49-53.
5. Kleine-Tebbe J, Galleani M, Jeep S et al. Basophil histamine release in patients with birch pollen hypersensitivity with and without allergic symptoms to fruits. Allergy 1992; 47(6):618-23.
6. Paris-Kohler A, Demoly P, Persi L et al. In vitro diagnosis of cypress pollen allergy by using cytofluorimetric analysis of basophils (Bastotest). J Allergy Clin Immunol 2000; 105(2 pt 1):339-45.
7. Nolte H, Storm K, Schiotz PO. Diagnostic value of a glass fibre-based histamine analysis for allergy testing in children. Allergy 1990; 45(3):213-23.