Allergy Skin Testing

Section: Miscellaneous
Effective Date: October 01, 2019
Revised Date: March 09, 2020
Last Reviewed: May 19, 2020

Description

An allergy is an abnormal reaction to an ordinarily harmless substance called an allergen. When an allergen (such as pollen) is absorbed into the body of an allergic individual that individual’s immune system views the allergen as an invader and a chain reaction is initiated. White blood cells of the immune system produce immune globulin E (IgE) antibodies. These antibodies attach themselves to special mast cells causing a release of potent chemicals such as histamine. Allergic or hypersensitivity disorders may be manifested by generalized systemic reactions in any organ system of the body. The reactions may be acute, sub-acute or chronic, immediate or delayed, and may be caused by an endless variety of fur, venoms, foods, drugs, etc. The ideal management of the allergic individual is to identify the offending agent by various means of testing.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person’s unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Criteria

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

Allergy testing may be considered medically necessary in the diagnosis of allergies by ANY ONE of the following techniques:

  • Direct Skin Test with ANY ONE of the following techniques:
    • Percutaneous (scratch, prick, or puncture) testing when IgE-mediated reactions occur with ANY ONE of the following indications:
      • Inhalants; or
      • Foods; or
      • Hymenoptera (stinging insects); or
      • Specific drugs (penicillin's and macromolecular agents).
    • Intracutaneous (intradermal) testing when IgE-mediated reactions occur with ANY ONE of the following indications:
      • Inhalants; or
      • Foods; or
      • Hymenoptera (stinging insects); or
      • Specific drugs (penicillin's and macromolecular agents.

A cumulative total of 70 percutaneous or 40 intracutaneous tests allowed per benefit year.

  • Patch test (application test) for diagnosing contact dermatitis or eosinophilic esophagitis; or
  • Photo patch test for diagnosing a photo-allergy (e.g., photo-allergic contact dermatitis); or
  • Bronchial challenge tests to diagnose ANY ONE of the following:
    • To identify new allergens for which skin or blood testing has not been validated; or
    • Skin testing is unreliable; or
  • Oral challenge tests for ANY of the following:
    • Food or other substances (i.e. additives or preservatives); or
    • Drugs when ALL of the following are met:
      • An allergy to multiple classes of drugs within a drug category is suspected (i.e. allergic to penicillin, and cephalosporins); and
      • There is no effective alternative drug; or
      • Treatment with that drug is essential.

Allergy testing not meeting the criteria above is considered not medically necessary.

Procedure Codes

95004 95017 95018 95024 95027 95028 95044
95052 95070 95071 95076 95079

 

Skin Endpoint Titration (SET) used in conjunction with immuno-therapy may be considered medically necessary with ANY ONE of the following when there is potential for the specific allergen in question to produce a severe systemic allergic reaction or anaphylaxis:

  • To determine a safe starting does for testing; or
  • To determine a safe starting dose for immuno-therapy.

A cumulative total of 80 tests for SET testing allowed per benefit year.

Procedure Codes

95017 95018 95027

 

Allergy testing methods are considered not medically necessary with ANY ONE of the following:

  • Cytotoxic food testing; or
  • Leukocyte histamine release; or
  • Provocative testing, e.g., Rinkel; or
  • Sublingual (antigens prepared for sublingual administration); or
  • Mucous Membrane Test (e.g., direct nasal, ophthalmic).

Procedure Codes

86343 95060 95065 95199

 

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes 95004, 95017, 95018, 95024, 95027, and 95028

C43.9 C51.0 C51.1 H10.10 H10.11 H10.12 H10.13
H10.411 H10.412 H10.413 H10.419 H10.44 H10.45 H16.261
H16.262 H16.263 H16.269 J30.0 J30.1 J30.2 J30.5
J30.81 J30.89 J30.9 J31.0 J32.0 J32.1 J32.2
J32.3 J32.4 J32.8 J32.9 J33.0 J33.8 J34.3
J44.0 J44.1 J44.9 J45.20 J45.21 J45.22 J45.30
J45.31 J45.32 J45.40 J45.41 J45.42 J45.50 J45.51
J45.52 J45.901 J45.902 J45.909 J45.991 J45.998 K52.21
K52.22 K52.29 K52.89 L20.0 L20.81 L20.82 L20.84
L20.89 L20.9 L27.2 L29.9 L50.0 L50.1 L50.6
L50.8 R05 R06.02 R11.0 R11.10 R11.11 R11.12
R11.2 R14.0 R14.1 R14.2 R14.3 R19.7 T36.0X5A
T36.0X5D T36.0X5S T36.1X5A T36.1X5D T36.1X5S T36.2X5A T36.2X5D
T36.2X5S T36.3X5A T36.3X5D T36.3X5S T36.4X5A T36.4X5D T36.4X5S
T36.5X5A T36.5X5D T36.5X5S T36.6X5A T36.6X5D T36.6X5S T36.7X5A
T36.7X5D T36.7X5S T36.8X5A T36.8X5D T36.8X5S T36.95XA T36.95XD
T36.95XS T37.1X5A T37.1X5D T37.1X5S T41.3X5A T41.3X5D T41.3X5S
T41.5X5A T41.5X5D T41.5X5S T43.605A T43.605D T43.605S T43.695A
T43.695D T43.695S T44.0X5A T44.0X5D T44.0X5S T44.1X5A T44.1X5D
T44.1X5S T44.2X5A T44.2X5D T44.2X5S T44.3X5A T44.3X5D T44.3X5S
T44.4X5A T44.4X5D T44.4X5S T44.5X5A T44.5X5D T44.5X5S T44.6X5A
T44.6X5D T44.6X5S T44.7X5A T44.7X5D T44.7X5S T44.8X5A T44.8X5D
T44.8X5S T44.905A T44.905D T44.905S T44.995A T44.995D T44.995S
T45.1X5A T45.1X5D T45.1X5S T46.0X5A T46.0X5D T46.0X5S T46.1X5A
T46.1X5D T46.1X5S T46.2X5A T46.2X5D T46.2X5S T46.3X5A T46.3X5D
T46.3X5S T46.6X5A T46.6X5D T46.6X5S T46.8X5A T46.8X5D T46.8X5S
T46.905A T46.905D T46.905S T46.995A T46.995D T46.995S T47.0X5A
T47.0X5D T47.0X5S T47.1X5A T47.1X5D T47.1X5S T47.2X5A T47.2X5D
T47.2X5S T47.3X5A T47.3X5D T47.3X5S T47.4X5A T47.4X5D T47.4X5S
T47.5X5A T47.5X5D T47.5X5S T47.6X5A T47.6X5D T47.6X5S T47.7X5A
T47.7X5D T47.7X5S T47.8X5A T47.8X5D T47.8X5S T47.95XA T47.95XD
T47.95XS T48.0X5A T48.0X5D T48.0X5S T48.1X5A T48.1X5D T48.1X5S
T48.205A T48.205D T48.205S T48.295A T48.295D T48.295S T48.3X5A
T48.3X5D T48.3X5S T48.4X5A T48.4X5D T48.4X5S T48.5X5A T48.5X5D
T48.5X5S T48.6X5A T48.6X5D T48.6X5S T48.905A T48.905D T48.905S
T48.995A T48.995D T48.995S T49.0X5A T49.0X5D T49.0X5S T49.2X5A
T49.2X5D T49.2X5S T49.3X5A T49.3X5D T49.3X5S T49.4X5A T49.4X5D
T49.4X5S T49.5X5A T49.5X5D T49.5X5S T49.6X5A T49.6X5D T49.6X5S
T49.7X5A T49.7X5D T49.7X5S T49.8X5A T49.8X5D T49.8X5S T49.95XA
T49.95XD T49.95XS T50.1X5A T50.1X5D T50.1X5S T50.2X5A T50.2X5D
T50.2X5S T50.3X5A T50.3X5D T50.3X5S T50.4X5A T50.4X5D T50.4X5S
T50.5X5A T50.5X5D T50.5X5S T50.6X5A T50.6X5D T50.6X5S T50.7X5A
T50.7X5D T50.7X5S T50.8X5A T50.8X5D T50.8X5S T50.905A T50.905D
T50.905S T50.995A T50.995D T50.995S T50.A15A T50.A15D T50.A15S
T50.A25A T50.A25D T50.A25S T50.A95A T50.A95D T50.A95S T50.B15A
T50.B15D T50.B15S T50.B95A T50.B95D T50.B95S T50.Z95A T50.Z95D
T50.Z95S T63.001A T63.001D T63.001S T63.002A T63.002D T63.002S
T63.003A T63.003D T63.003S T63.004A T63.004D T63.004S T63.011A
T63.011D T63.011S T63.012A T63.012D T63.012S T63.013A T63.013D
T63.013S T63.014A T63.014D T63.014S T63.021A T63.021D T63.021S
T63.022A T63.022D T63.022S T63.023A T63.023D T63.023S T63.031A
T63.031D T63.031S T63.032A T63.032D T63.032S T63.033A T63.033D
T63.033S T63.034A T63.034D T63.034S T63.041A T63.041D T63.041S
T63.042A T63.042D T63.042S T63.043A T63.043D T63.043S T63.044A
T63.044D T63.044S T63.061A T63.061D T63.061S T63.062A T63.062D
T63.062S T63.063A T63.063D T63.063S T63.064A T63.064D T63.064S
T63.071A T63.071D T63.071S T63.072A T63.072D T63.072S T63.073A
T63.073D T63.073S T63.074A T63.074D T63.074S T63.081A T63.081D
T63.081S T63.082A T63.082D T63.082S T63.083A T63.083D T63.083S
T63.084A T63.084D T63.084S T63.091A T63.091D T63.091S T63.092A
T63.092D T63.092S T63.093A T63.093D T63.093S T63.094A T63.094D
T63.094S T63.111A T63.111D T63.111S T63.112A T63.112D T63.112S
T63.113A T63.113D T63.113S T63.114A T63.114D T63.114S T63.121A
T63.121D T63.121S T63.122A T63.122D T63.122S T63.123A T63.123D
T63.123S T63.124A T63.124D T63.124S T63.191A T63.191D T63.191S
T63.192A T63.192D T63.192S T63.193A T63.193D T63.193S T63.194A
T63.194D T63.194S T63.2X1A T63.2X1D T63.2X1S T63.2X2A T63.2X2D
T63.2X2S T63.2X3A T63.2X3D T63.2X3S T63.2X4A T63.2X4D T63.2X4S
T63.301A T63.301D T63.301S T63.302A T63.302D T63.302S T63.303A
T63.303D T63.303S T63.304A T63.304D T63.304S T63.311A T63.311D
T63.311S T63.312A T63.312D T63.312S T63.313A T63.313D T63.313S
T63.314A T63.314D T63.314S T63.321A T63.321D T63.321S T63.322A
T63.322D T63.322S T63.323A T63.323D T63.323S T63.324A T63.324D
T63.324S T63.331A T63.331D T63.331S T63.332A T63.332D T63.332S
T63.333A T63.333D T63.333S T63.334A T63.334D T63.334S T63.391A
T63.391D T63.391S T63.392A T63.392D T63.392S T63.393A T63.393D
T63.393S T63.394A T63.394D T63.394S T63.411A T63.411D T63.411S
T63.412A T63.412D T63.412S T63.413A T63.413D T63.413S T63.414A
T63.414D T63.414S T63.421A T63.421D T63.421S T63.422A T63.422D
T63.422S T63.423A T63.423D T63.423S T63.424A T63.424D T63.424S
T63.431A T63.431D T63.431S T63.432A T63.432D T63.432S T63.433A
T63.433D T63.433S T63.434A T63.434D T63.434S T63.441A T63.441D
T63.441S T63.442A T63.442D T63.442S T63.443A T63.443D T63.443S
T63.444A T63.444D T63.444S T63.451A T63.451D T63.451S T63.452A
T63.452D T63.452S T63.453A T63.453D T63.453S T63.454A T63.454D
T63.454S T63.461A T63.461D T63.461S T63.462A T63.462D T63.462S
T63.463A T63.463D T63.463S T63.464A T63.464D T63.464S T63.481A
T63.481D T63.481S T63.482A T63.482D T63.482S T63.483A T63.483D
T63.483S T63.484A T63.484D T63.484S T63.511A T63.511D T63.511S
T63.512A T63.512D T63.512S T63.513A T63.513D T63.513S T63.514A
T63.514D T63.514S T63.591A T63.591D T63.591S T63.592A T63.592D
T63.592S T63.593A T63.593D T63.593S T63.594A T63.594D T63.594S
T63.611A T63.611D T63.611S T63.612A T63.612D T63.612S T63.613A
T63.613D T63.613S T63.614A T63.614D T63.614S T63.621A T63.621D
T63.621S T63.622A T63.622D T63.622S T63.623A T63.623D T63.623S
T63.624A T63.624D T63.624S T63.631A T63.631D T63.631S T63.632A
T63.632D T63.632S T63.633A T63.633D T63.633S T63.634A T63.634D
T63.634S T63.691A T63.691D T63.691S T63.692A T63.692D T63.692S
T63.693A T63.693D T63.693S T63.694A T63.694D T63.694S T63.711A
T63.711D T63.711S T63.712A T63.712D T63.712S T63.713A T63.713D
T63.713S T63.714A T63.714D T63.714S T63.791A T63.791D T63.791S
T63.792A T63.792D T63.792S T63.793A T63.793D T63.793S T63.794A
T63.794D T63.794S T63.811A T63.811D T63.811S T63.812A T63.812D
T63.812S T63.813A T63.813D T63.813S T63.814A T63.814D T63.814S
T63.821A T63.821D T63.821S T63.822A T63.822D T63.822S T63.823A
T63.823D T63.823S T63.824A T63.824D T63.824S T63.831A T63.831D
T63.831S T63.832A T63.832D T63.832S T63.833A T63.833D T63.833S
T63.834A T63.834D T63.834S T63.891A T63.891D T63.891S T63.892A
T63.892D T63.892S T63.893A T63.893D T63.893S T63.894A T63.894D
T63.894S T63.91XA T63.91XD T63.91XS T63.92XA T63.92XD T63.92XS
T63.93XA T63.93XD T63.93XS T63.94XA T63.94XD T63.94XS T78.00XA
T78.00XD T78.00XS T78.01XA T78.01XD T78.01XS T78.02XA T78.02XD
T78.02XS T78.03XA T78.03XD T78.03XS T78.05XA T78.05XD T78.05XS
T78.06XA T78.06XD T78.06XS T78.07XA T78.07XD T78.07XS T78.08XA
T78.08XD T78.08XS T78.09XA T78.09XD T78.09XS T78.1XXA T78.1XXD
T78.1XXS T78.2XXA T78.2XXD T78.2XXS T78.3XXA T78.3XXD T78.3XXS
T88.6XXA T88.6XXD T88.6XXS Z88.0 Z88.1

Covered Diagnosis Codes for Procedure Code 95044

K20.0 L20.0 L20.9 L20.81 L20.82 L20.84 L20.89
L23.0 L23.1 L23.2 L23.3 L23.5 L23.6 L23.7
L23.9 L23.81 L24.0 L24.1 L24.2 L24.3 L24.4
L24.5 L24.6 L24.7 L24.9 L24.81 L25.0 L25.3
L25.4 L25.5 L25.9 L30.0 L30.2 L30.8 L30.9
L50.0

Covered Diagnosis Codes for Procedure Code 95052

L56.0 L56.1 L56.2 L56.3 L56.8

Covered Diagnosis Codes for Procedure Codes 95076, and 95079

L27.2 T36.0X5A T36.0X5D T36.0X5S T50.995A T50.995D T50.995S
T78.00XA T78.00XD T78.00XS T78.01XA T78.01XD T78.01XS T78.02XA
T78.02XD T78.02XS T78.03XA T78.03XD T78.03XS T78.04XA T78.04XD
T78.04XS T78.05XA T78.05XD T78.05XS T78.06XA T78.06XD T78.06XS
T78.07XA T78.07XD T78.07XS T78.08XA T78.08XD T78.08XS T78.09XA
T78.09XD T78.09XS T78.1XXA T78.1XXD T78.1XXS

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-26-2019 updated coding

Internal Medical Policy Committee 5-19-2020 Annual review

Links

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.