Medical Policy: 02.01.02
Original Effective Date: November 2003
Reviewed: April 2016
Revised: April 2016
Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.
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. Skin testing would be the first line of testing for the majority of patients. In vitro testing would be appropriate necessary for those with the inability to stop specific medications and those that have had severe allergic responses to medicine, food, inhalants, and insectsand insects. It would be inappropriate to use in vitro testing for the majority of patients as the first line of testing.
Allergy is a hypersensitive reaction that is usually manifested in the clinical form of allergic asthma, hay fever or eczema developing within minutes to a few hours after exposure to an antigen. The most common types of allergies are rhinitis, asthma, food allergy, insect sting allergy, drug allergy and contact dermatitis. Allergy testing is focused on determining what allergens cause a particular reaction and the degree of the reaction and provides justification for recommendations of specific avoidance measures in the home or work environment or the institution of particular medicines or immunotherapy. There are virtually no age limitations for performance of skin tests. However, skin test reactivity may be diminished in infants and the elderly. Types of allergy testing include in vivo, in vitro, provocation testing, and controversial allergy tests. The umbrella term ‘food hypersensitivity or food sensitivities’ can be used to describe any ‘adverse reaction to food’. The term ‘food allergy’ refers to the subgroup of food-triggered reactions in which immunologic mechanisms have been implicated, whether IgE- mediated, non-IgE-mediated, or involving a combination of IgE- and non-IgE-mediated etiologies. All other reactions to food that were in the past sometimes referred to as ‘food intolerance’ or ‘food sensitivities’ constitute non-allergic food hypersensitivity reactions and are not considered allergies.
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.
The Choosing Wisely initiative includes the following recommendations from the American Academy of Asthma, Allergy, and Immunology regarding allergy testing:
Don’t perform unproven diagnostic tests, such as immunoglobulin G (IgG) testing or an indiscriminate battery of immunoglobulin E (IgE) tests, in the evaluation of allergy
Don’t routinely do diagnostic testing in patients with chronic urticaria.
Don’t perform food IgE testing without a history consistent with potential IgE-mediated food allergy.
One of the AAAAI’s (American Academy of Allergy, Asthma and Immunology) “Five Things Physicians and Patients Should Question” (2012) noted that “Appropriate diagnosis and treatment of allergies requires specific IgE testing (either skin or blood tests) based on the patient’s clinical history. The use of other tests or methods to diagnose allergies is unproven and can lead to inappropriate diagnosis and treatment”. The AAAAI stated that “Don’t perform unproven diagnostic tests, such as immunoglobulin G (IgG) testing or an indiscriminate battery of immunoglobulin E (IgE) tests, in the evaluation of allergy”.
Updated Practice Parameter (2012) states: Summary Statement 127. IgG and IgG subclass antibody tests for food allergy do not have clinical relevance, are not validated, lack sufficient quality control, and should not be performed.
Evidence of IgE sensitization to common food and appropriate aeroallergens can support a diagnosis of food allergy in conjunction with clinical history and/or food challenge. The clinical utility of measuring serum food IgE and to generate a successful elimination diet needs further investigation. There are no unconventional tests which can be recommended as an alternative or complementary diagnostic tool in the workup of suspected food allergy, and their use should be discouraged.
The following allergy tests are considered medically necessary, if the following indications are met, with the following limits:
Percutaneous (scratch, puncture, prick) and intracutaneous (intradermal) allergy testing are considered medically necessary and, therefore, covered for the diagnosis, evaluation, and treatment of allergies when there are signs and symptoms or a diagnosis suggestive of an allergy (eg, a history of hypersensitivity to animals, food, pollen, dust mites, mold, grass, insect venoms; or asthma, allergic rhinitis, urticaria) with the following limitations:
A cumulative total of 70 scratch, puncture, or prick allergy tests are eligible for reimbursement per calendar year (CPY code 95004).
A cumulative total of 40 intracutaneous allergy tests (which should only follow negative scratch, puncture, or prick tests) are eligible for reimbursement per calendar year (CPT codes 95024 and 95028).
Skin serial endpoint titration (SET) for determination of a safe starting dose for testing or immunotherapy when there is potential for the specific allergen in question to produce a severe systemic reaction or anaphylaxis and it is an approved indication for immunotherapy. The use of serial endpoint testing should not replace routine use of prick/puncture testing. Serial endpoint titration (SET) testing (eg, intradermal dilutional testing [IDT]) is considered medically necessary with a cumulative total of 80 tests being eligible for reimbursement per calendar year (CPT codes 95017, 95018, and 95027).
Allergy testing in excess of the above limits is considered not medically necessary.
Multiallergen screening (CPT code 86005) is a qualitative test that does not quantify specific antigens; therefore, it is considered not medically necessary and not covered. Multiallergen screening is considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support its use in the treatment of illness.
The following allergy tests are considered investigational because the scientific literature has not provided proof of their efficacy:
The use of in vitro (blood) (86003) allergy testing for IgE should be limited to individuals where skin testing is not possible. An initial allergy screen is up to 12 tests. Additional tests may be medically necessary if any of the initial test results are positive. If all test results are negative, additional testing beyond the initial allergy screen of 12 tests/allergens is considered not medically necessary. There would rarely be a need for testing beyond 36 test per year. Testing implemented beyond 48 tests will be denied as not medically necessary.
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.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.