Point32 Allergy Testing and Immunotherapy Form

Allergy Testing

The Plan considers allergy testing as reasonable and medically necessary when ONE following are met:

1. Percutaneous Tests when documentation confirms testing is required for reaction to ONE of the following:
   • Foods where individuals present signs or symptoms of urticarial, angioedema, eosinophilic esophagitis, or anaphylaxis after ingestion of specific foods; or
   • Hymenoptera; or
   • Specific drugs (e.g., penicillin, macromolecular agents, enzymes, egg-containing vaccines)
2. Intracutaneous/Intradermal Tests when documentation confirms percutaneous tests are negative and there is suspected allergen sensitivity to ONE of the following:
   • Inhalants; or
   • Hymenoptera; or
   • Specific drugs (e.g., penicillin, macromolecular agents); or
   • Vaccines
3. Patch Tests when documentation confirms the test will be utilized to diagnose allergic contact dermatitis after ONE of the following exposures:
   • Dermatitis due to detergents; or
   • Oils and greases; or
   • Solvents, drugs, and medicines in contact with skin; or
   • Food in contact with skin; or
   • Plants; or
   • Cosmetics; or
   • Metals or rubber additives
4. Photo Patch Testing to diagnose suspected allergies resulting from light exposure (e.g., photo-allergic contact dermatitis); or
5. Photo Tests to evaluate photo-sensitivity disorders; or
6. Delayed Hypersensitivity Skin Testing for allergen testing, testing for infection with intracellular pathogens, or testing for sensitivity to contact allergens; or
7. Ingestion (Oral) Challenge Test when documentation confirms ONE of the following:
   • Food allergy dermatitis; or
   • Anaphylactic shock due to adverse food reaction; or
   • Allergy to medicinal agents; or
   • Allergy to foods; or
8. Allergy has resolved or has been disproven; or
9. In Vitro Allergy Testing when skin testing is not possible, and documentation confirms ANY of the following criteria:
   • Individual has a skin condition that will not make direct skin testing possible; or
   • Individual requires continued use of H-1 blockers (antihistamines), or in the rare patient with persistent unexplained negative histamine control; or
   • Individual cannot be safely withdrawn from medications that interfere with skin testing; or
   • Testing is difficult due to mental or physical impairments; or
   • To evaluate cross-reactivity between insect venoms (e.g., fire ant, bee, wasp, yellow jacket, hornet); or
   • To utilize for adjunctive laboratory testing for disease activity of allergic bronchopulmonary aspergillosis and certain parasitic disease; or
   • To diagnose atopy in small children; or
   • Individual is at increased risk for anaphylactic response from skin testing based on clinical history; or who has a history of a previous systemic reaction to skin testing; or
   • Skin testing was inconclusive and in vitro testing is required as a confirmatory test.

Exclusions: The Plan considers allergen testing as not medically necessary for all other indications. In addition, The Plan does not cover:

• Serum IgG testing or IgG subclass testing for any specific allergens

Allergen Immunotherapy

1. The Plan considers allergen immunotherapy as reasonable and medically necessary when administered under the supervision of an appropriately trained physician and when documentation confirms ONE of the following:
2. Diagnosis of Allergic Asthma, Allergic Conjunctivitis, Allergic Rhinitis, or Stinging Insect Hypersensitivity when ALL of the following are met:
   • Results of allergy testing show immediate hypersensitivity to skin tests or in vitro tests for specific immunoglobulin E (IgE); and
   • Contraindication to or failed maintenance by pharmacologic therapy; and Individual’s treatment plan, dosage and immunotherapy schedule, antigens to be administered, and target maintenance dose for allergy immunotherapy.
3. Stinging Insect Immunotherapy when ALL of the following are met:
   • Diagnosis of anaphylaxis after an insect sting or hives alone in children under 16 years of age; and
   • Positive skin test or other documented IgE sensitivity to specific stinging insect venom
4. Allergy Immunotherapy for the ONE of the following

4. Allergy Immunotherapy for the treatment of ONE of the following:
   • Animal dander sensitivity (epidermal) when documentation confirms antihistamines do not relieve symptoms; or
   • Standardized dust mite extracts or perennials such as cat and dog dander and cockroach; or
   • Delayed systemic reactions with symptoms of anaphylaxis with a positive skin test or presence of venom-specific IgE; or
   • Rapid desensitization for cases of allergy to insulin, penicillin, sulfonamides, cephalosporins and other commonly used drugs.

Patch Tests for diagnosing allergic contact dermatitis

Medical necessity criteria and limitations for Patch Tests for diagnosing allergic contact dermatitis are as follows: Patch Tests are considered medically necessary when documentation confirms the test will be utilized to diagnose allergic contact dermatitis after exposure to one of the following:

• Dermatitis due to detergents;
• Oils and greases;
• Solvents, drugs, and medicines in contact with skin;
• Food in contact with skin;
• Plants;
• Cosmetics;
• Metals or rubber additives.

Exclusions to this are allergen testing considered not medically necessary for all other indications, and The Plan does not cover serum IgG testing or IgG subclass testing for any specific allergens.

Photo Patch Testing for allergies resulting from light exposure

Medical necessity criteria and limitations for Photo Patch Testing are as follows: Photo Patch Testing is considered reasonable and medically necessary for diagnosing suspected allergies resulting from light exposure (e.g., photo-allergic contact dermatitis).

Ingestion (Oral) Challenge Test for food allergy dermatitis, anaphylactic shock due to adverse food reaction, allergy to medicinal agents, or allergy to foods

The Plan considers Ingestion (Oral) Challenge Test when documentation confirms ONE of the following:

• Food allergy dermatitis;
• Anaphylactic shock due to adverse food reaction;
• Allergy to medicinal agents;
• Allergy to foods.

In Vitro Allergy Testing when skin testing is not possible

In Vitro Allergy Testing when skin testing is not possible, and documentation confirms ANY of the following criteria:

• Individual has a skin condition that will not make direct skin testing possible; or
• Individual requires continued use of H-1 blockers (antihistamines), or in the rare patient with persistent unexplained negative histamine control; or
• Individual cannot be safely withdrawn from medications that interfere with skin testing; or
• Testing is difficult due to mental or physical impairments; or
• To evaluate cross-reactivity between insect venoms (e.g., fire ant, bee, wasp, yellow jacket, hornet); or
• To utilize for adjunctive laboratory testing for disease activity of allergic bronchopulmonary aspergillosis and certain parasitic diseases; or
• To diagnose atopy in small children; or
• Individual is at increased risk for anaphylactic response from skin testing based on clinical history, or who has a history of a previous systemic reaction to skin testing; or
• Skin testing was inconclusive and in vitro testing is required as a confirmatory test.