264 Form

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Medical Policy Diagnosis and Management of Idiopathic Environmental Intolerance or Clinical Ecology Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 264

BCBSA Reference Number: 2.01.01A (For Plan internal use only) NCD/LCD: N/A Related Policies
• Fecal Analysis in the Diagnosis of Intestinal Dysbiosis, #556 • Intracellular Micronutrient Analysis, #073 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

Laboratory tests designed to affirm the diagnosis of idiopathic environmental intolerance is INVESTIGATIONAL.

Treatments for idiopathic environmental intolerance, including but not limited to IVIg, neutralizing therapy of chemical and food extracts, avoidance therapy, elimination diets, and oral nystatin (to treat Candida) are INVESTIGATIONAL.

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.

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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.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable. CPT Codes There is no specific CPT code for this service. Description Idiopathic environmental intolerance is typically characterized by recurrent, nonspecific symptoms that the patient believes are provoked by low levels of exposure to chemical, biologic, or physical agents. The most common environmental exposures include perfumes and scented products, pesticides, domestic and industrial solvents, new carpets, car exhaust, gasoline and diesel fumes, urban air pollution, cigarette smoke, plastics, and formaldehyde. Certain foods, food additives, drugs, electromagnetic fields, and mercury in dental fillings have also been reported as triggering events. However, symptoms do not bear any relationship to established toxic effects of the specific chemical and occur at concentrations far below those expected to elicit toxicity.
Reported symptoms are markedly variable but generally involve the central nervous system, respiratory and mucosal irritation, or gastrointestinal symptoms. In contrast to the frequently debilitating symptomatology, no specific and consistent abnormalities are noted on laboratory or other diagnostic testing. The variable nature of the reported symptoms and the lack of recognized pathologic abnormalities make it extremely difficult to establish objective diagnostic criteria for the condition, which further hinders research into both the causes and appropriate treatment.
An example of nutritional environmental intolerance testing includes the Functional Intracellular Analysis (FIA™) from SpectraCell labs that measure the intracellular levels of micronutrients, such as vitamins, minerals, and antioxidants in lymphocytes. All environmental tolerance testing is considered investigational regardless of the commercial name the manufacturer or FDA approval status. Summary There is a lack of clear diagnostic criteria for idiopathic environmental intolerance (also known as multiple chemical sensitivities) and a lack of evidence on the diagnostic accuracy of laboratory or other tests for this condition. Overall, studies using existing criteria have not found that subjects diagnosed with the condition can reliably distinguish between chemical exposure and placebo. Moreover, studies have not consistently found that low-level electromagnetic field exposure affects objective outcomes eg, heart rate or cognitive function. In addition, there is a lack of controlled studies to evaluate treatments for idiopathic environmental intolerance. Thus, all tests and treatments for this condition are considered investigational. Policy History Date Action 9/2022 Annual policy review. Policy updated with literature review through September 2022. References added. Policy statements unchanged. 12/2019 Policy updated with literature review through December 1, 2019, references added. Policy statements unchanged. 7/2014 Annual policy review. Wording in statement on treatment modified for clarification. 6/2013 Annual policy review. New references added. 2/04/2013 Annual policy review. No changes to policy statements; title revised. 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/Asthma/Immunology and

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ENT/Otolaryngology. No changes to policy statements. 9/01/2010 Medical Policy #264 created.
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 Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines References

1. Aaron LA, Buchwald D. A review of the evidence for overlap among unexplained clinical conditions. Ann Intern Med 2001; 134(9 pt 2):868-81.
2. Barsky AJ, Borus JF. Functional somatic syndromes. Ann Intern Med 1999; 130(11):910-21.
3. Graveling RA, Pilkington A, George JP et al. A review of multiple chemical sensitivity. Occup Environ Med 1999; 56(2):73-85.
4. Lacour M, Zunder T, Huber R et al. The pathogenetic significance of intestinal Candida colonization-- a systematic review from an interdisciplinary and environmental medical point of view. Int J Hyg Environ Health 2002; 205(4):257-68.
5. Winder C. Mechanisms of multiple chemical sensitivity. Toxicol Lett 2002; 128(3-Jan):85-97.
6. Das-Munshi J, Rubin GJ, Wessely S. Multiple chemical sensitivities: a systematic review of provocation studies. J Allergy Clin Immunol 2006; 118(6):1257-64.
7. Bailer J, Witthoft M, Rist F. Psychological predictors of short- and medium term outcome in individuals with idiopathic environmental intolerance (IEI) and individuals with somatoform disorders. J Toxicol Environ Health A 2008; 71(11-12):766-75.
8. Witthoft M, Rist F, Bailer J. Evidence for a specific link between the personality trait of absorption and idiopathic environmental intolerance. J Toxicol Environ Health A 2008; 71(11-12):795-802.
9. Skovbjerg S, Zachariae R, Rasmussen A et al. Attention to bodily sensations and symptom perception in individuals with idiopathic environmental intolerance. Environ Health Prev Med 2010; 15(3):141-50.
10. Skovberg S, Zachariae R, Rasumussen R et al. Regressive coping and alexithymia in idiopathic environmental intolerance. Environ Health Prev Med 2010; 15(5):299-310.
11. Skovbjerg S, Rasmussen A, Zachariae R et al. The association between idiopathic environmental intolerance and psychological distress, and the influence of social support and recent major life events. Environ Health Prev Med 2012; 17(1):2-9.
12. Bornschein S, Hausteiner C, Rommelt H et al. Double-blind placebo-controlled provocation study in patients with subjective Multiple Chemical Sensitivity (MCS) and matched control subjects. Clin Toxicology 2008; 46(5):443-9.
13. Rubin GJ, Hillert L, Nieto-Hernandez R et al. Do people with idiopathic environmental intolerance attributed to electromagnetic fields display physiological effects when exposed to electromagnetic fields A. systematic review of provocation studies. Bioelectromagnetics 2011; 32(8):593-609.
14. Baliatsas C, Van Kamp I, Lebret E et al. Idiopathic environmental intolerance attributed to electromagnetic fields (IEI-EMF): a systematic review of identifying criteria. BMC Public Health 2012; 12:643.
15. Skovbjerg S, Hauge CR, Rasmussen A et al. Mindfulness-based cognitive therapy to treat multiple chemical sensitivities: a randomized pilot trial. Scand J Psychol 2012; 53(3):233-8.
16. Sponsored by The Danish Research Centre for Chemical Sensitivities. Pulsed Electromagnetic Fields for Multiple Chemical Sensitivity (NCT01834781). Available online at: www.clinicaltrials.gov. Last accessed March, 2014.
17. American Academy of Allergy Asthma and Immunology Position Statement on Idiopathic Environmental Intolerances. 1999. Available online at: http://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/Practice%20and%20Param eters/Idiopathic-environmental-intolerances-1999.pdf. Last accessed February, 2014.

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18. American College of Occupational Environmental Medicine Position Statement. Multiple chemical sensitivities: idiopathic environmental intolerance. J Occup Environ Med 1999; 41(11):940-2.
19. Verrender A, et al. IEI-EMF provocation case studies: A novel approach to testing sensitive individuals. Bioelectromagnetics 2018 - Clinical Trial. PMID 29125197
20. Tran MTD, et al. A randomised, placebo-controlled trial of transcranial pulsed electromagnetic fields in patients with multiple chemical sensitivity. Acta Neuropsychiatr 2017 - Clinical Trial. PMID 27919300
21. Verrender A, et al. Can explicit suggestions about the harmfulness of EMF exposure exacerbate a nocebo response in healthy controls? Environ Res 2018 - Clinical Trial. PMID 29936289
22. Hauge CR, et al. Mindfulness-based cognitive therapy (MBCT) for multiple chemical sensitivity (MCS): Results from a randomized controlled trial with 1 year follow-up. J Psychosom Res 2015 - Clinical Trial. PMID 26311155
23. Witthöft M, et al. On the origin of worries about modern health hazards: Experimental evidence for a conjoint influence of media reports and personality traits. Psychol Health 2018 - Clinical Trial. PMID 28758796
24. Po-Chang Huang et al. Physiological changes and symptoms associated with short-term exposure to electromagnetic fields: a randomized crossover provocation study. Environ Health 2022 Mar 8;21(1):31.