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Medical Policy: 02.01.02
Original Effective Date: November 2003
Reviewed: July 2008
Revised: January 2005
This policy applies to all products unless specific contract
limitations, exclusions or exceptions apply. Please refer to the member's coverage
manual for benefit availability. Managed care guidelines related to referral authorization,
and precertification of inpatient hospitalization, home health, home infusion and
hospice services apply.
Description:
Allergic or hypersensitivity disorders can manifest themselves as generalized systemic reactions as well as localized reactions in any organ system of the body. Numerous agents, e.g., pollen, mold, dust mites, animal dander, insect stings, foods or drugs may precipitate allergic or hypersensitive reactions. For details on treatment of allergies, see Policy 02.01.01, Allergy Immunotherapy.
The management of an allergic patient should include a comprehensive history, physical examination and should include confirming the cause of allergies. Once the agent is identified, treatment is provided by avoidance, medication or immunotherapy.
Allergy tests detect the presence of IgE antibodies to a particular allergen, or something that causes an allergic reaction. A positive test suggests allergic sensitization to a specific allergen. There are several in-vitro tests available to diagnose allergies, however, the National Medical and Research Center believes that standard intradermal or epicutaneous skin tests in correlation with a thorough medical history and physical examination best serves the paitent. A positive skin test alone does not diagnose an allergy; it must correlate with symptoms experienced when the patient has an allergen exposure.
Policy:
The following allergy tests may be considered medically necessary:
Percutaneous or epicutaneous testing when IgE-mediated reactions occur to any of the following allergens;
- Aerollergans (such as pollen, mold, dust mites, grass, ragweed, trees)
- Foods
- Hymenoptera (stinging insects)
- Specific drugs (penicillins and molecular agents)
Intradermal or intracutaneous testing when IgE-mediated reactions occur to any of the following allergens;
- Aeroallergans
- Foods
- Hymenoptera (stinging insects)
- Specific drugs (penicillins and macromolecular agents)
Intradermal, or intracutaneous tests with allergenic extracts are based on a wheal and flare reaction within 15-20 minutes
Number of Skin Tests Required:
The evaluation of inhalant allergies may occasionally require a panel of percutaneous tests. However in most cases, a smaller number of tests are required.
Skin Patch test for diagnosing contact allergic dermatitis
Bronchial Challenge testing with antigens or histimine or methachoine to identify new allergies when skin testing is not possible.
Ingestion (oral) challenge test for the following
- Food or other substances (i.e. metabisulfite)
- Drugs, when all of the following are met;
- History of allergy to a particular drug
- Treatment with that drug class is essential
- There is no effective alternative drug
RAST, FAST, ELISA, (86003) PRIST, RIST, MAST, (86005) MRT, VAST, and ImmunoCAP tests (95199); may be considered medically necessary when percutaneous testing of IgE-mediated allergies to inhalant allergens, foods, insect stings and other allergens such as drugs, can’t be done due to any of the following reasons:
- Patient has severe dermatographism, ichthyosis or generalized eczema
- Patients who are unable to discontinue antihistamines but who are in need of allergy testing
- Difficulty in testing uncooperative patients (e.g. small children or patients with mental or physical impairments)
- When clinical history suggests an unacceptable risk of respiratory insufficiency or anaphylaxis from skin testing
- Skin testing is inconclusive or if the patient is taking a beta blocker that cannott be discontinued.
These tests may also be covered as an alternative to percutaneous testing for
- The evaluation of cross-reactivity between insect venoms
- As adjunctive laboratory tests for disease activity of allergic bronchopulmonary aspergillosis and certain parasitic diseases
- Cases when direct skin tests for drugs are inconclusive
The following allergy tests are considered investigational because the scientific literature has not provided proof of their efficacy:
- Provocative tests (e.g. Rinkel test) for food or food additive allergies
- Nasal challenge test
- Conjunctival challenge test
- Leukocyte histamine release test (LHRT)
- Rebuck Skin Window test
- Passive transfer or P-X (Prausnitz-Kustner) test (replaced by radioallergosorbent test)
- Cytotoxic food testing
- Serial end point test for diagnosis and treatment of allergic disorders
- Any testing related to the Nambudripad's Allergy Elimination Technique (NAET)
- Any IgG in-vitro assay used for evaluation
- Sublingual allergy desensitization to aerollergens not recommended by the American Academy of Allergy
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Procedure Codes and Billing
Guidelines:
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To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
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Selected References:
- The Medical Policy Reference Manual (MPRM) developed by the Blue Cross Blue Shield Association Health Management Systems, based on Technology Evaluation Center (TEC) criteria.
- TEC assessment by Blue Cross Blue Shield Association, Serial endpoint testing for the diagnosis and treatment of allergic disorders. TEC Bulletin April 5, 2002;volume 19#1:22-24.
- LMRP Allergy Testing June 1, 2000. Med A News Issue #2006:42-43.
- U.S. Food and Drug Administration (FDA) Compliance Policy Guidelines Section 370.100; Cytotoxic Testing for Allergic Diseases(CPG 7124.27).
- American Academy of Allergy: Position Statements-Controversial techniques. Journal of Allergy and Clinical Immunology 67:333-338 1980. Reaffirmed 1984.
- Sicherer, SH. Manifestations of food allergy: Evaluation and management. American Family Physician 59:415-424, 1999
- Barrett S, Index of Questionable Treatments; Nambudripad's Allergy Elimination Technique (NAET); www.quackwatch.org; Accessed on the web 12/20/05.
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New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309
*Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.
Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
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