In Vitro Allergy Testing

Policy ID: L-3-027

Effective Date: February 01, 2019

Revised Date: June 07, 2019

Revision Effective Date: March 03, 2025

Last Reviewed: January 14, 2025

Applies To: Commercial and Medicaid Expansion

Description

In vitro allergy testing determines whether an individual's serum contains immunoglobulin E (IgE) antibodies against specific allergens of clinical importance. The radioallergosorbent (RAST) test was developed for in vitro (blood) measurement of specific IgE in an individual's serum. There are several other tests that employ the same principle using different detection systems.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date; and/or

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

In vitro allergy testing for IgE may be considered medically necessary when ANY of the following are met:

Direct skin testing is impossible due to an extensive dermatitis or marked dermatographism; or
Direct skin testing is contraindicated because of concomitant drug treatment (e.g., psychotropic drugs frequently have H1 blocking characteristics); or
When there is difficulty in testing uncooperative individuals (e.g., small children or individuals with mental or physical impairments); or
If direct skin testing has been inconclusive; or
As adjunctive tests for allergic bronchopulmonary aspergillosis or parasitic disease; or
Individuals who have a clinical history suggesting an unusually greater risk for anaphylaxis or who have had a previous systemic reaction to skin
testing; or
For evaluation of cross-reactivity between insect venoms.

In vitro allergy testing for IgE exceeding 36 tests per year is considered not medically necessary. In vitro allergy testing for IgE that does not meet the criteria of this policy is considered not medically necessary.

Procedure Codes

86003

86008

ELISA/ACT Qualitative Antibody Testing

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

ELISA/ACT qualitative antibody testing is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

86353

86849

IgG ELISA

Policy Application

IgG ELISA, indirect method, is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Code

86001

ALCAT (Antigen Leukocyte Cellular Antibody Test) Allergy Testing

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

ALCAT (Antigen Leukocyte Cellular Antibody Test) allergy testing is considered experimental/investigational and therefore non-covered and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Code

83516

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020 Annual Review

Internal Medical Policy Committee 1-19-2021 Annual Review

Internal Medical Policy Committee 1-20-2022 Annual Review

Internal Medical Policy Committee 1-26-2023 Annual Review

Internal Medical Policy Committee 1-16-2024 Annual Review-no changes in criteria.

Internal Medical Policy Committee 1-14-2025 Annual Review-no changes in criteria.

Added Policy Application

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: L-3-026

Section: Laboratory

Effective Date: February 01, 2019

Revised Date: June 07, 2019

Last Reviewed: January 26, 2023

Archived Date: March 03, 2024

Applies To: Commercial and Medicaid Expansion

Description

In vitro allergy testing determines whether an individual's serum contains immunoglobulin E (IgE) antibodies against specific allergens of clinical importance. The radioallergosorbent (RAST) test was developed for in vitro (blood) measurement of specific IgE in an individual’s serum. There are several other tests that employ the same principle using different detection systems.

Criteria

In vitro allergy testing for IgE may be considered medically necessary when ANY of the following are met:

Direct skin testing is impossible due to an extensive dermatitis or marked dermatographism; or
Direct skin testing is contraindicated because of concomitant drug treatment (e.g., psychotropic drugs frequently have H1 blocking characteristics); or
When there is difficulty in testing uncooperative individuals (e.g., small children or individuals with mental or physical impairments); or
If direct skin testing has been inconclusive; or
As adjunctive tests for allergic bronchopulmonary aspergillosis or parasitic disease; or
Individuals who have a clinical history suggesting an unusually greater risk for anaphylaxis or who have had a previous systemic reaction to skin
testing; or
For evaluation of cross-reactivity between insect venoms.

Procedure Codes

86003

86008

Procedure Codes

86353

86849

Procedure Code

86001

ALCAT (Antigen Leukocyte Cellular Antibody Test) allergy testing is considered experimental/investigational and therefore non-coveredand therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Code

83516

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020 Annual Review

Internal Medical Policy Committee 1-19-2021 Annual Review

Internal Medical Policy Committee 1-20-2022 Annual Review

Internal Medical Policy Committee 1-26-2023 Annual Review

Links

References (PDF)

Disclaimer

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