Medicare Advantage

Policy

Guidelines

MPGuidelinesPub

This policy is consistent with Medicare's coverage determination. The Company's payment methodology may differ from Medicare. ​

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, in vivo allergy sensitivity testing is covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met. However, services that are identified in this policy as experimental/investigational or not medically necessary are not eligible for coverage or reimbursement by the Company.

BILLING GUIDELINES

If percutaneous or intracutaneous (intradermal) sequential and incremental injections and single injection tests are performed on the same date of service, both the sequential and incremental injection and single injection test codes may be reported if the tests are different allergens or different dilutions of the same allergen.

The unit of service to report is the number of separate injections. Do not report both a single injection test and a sequential and incremental injection test for the same dilution of an allergen. For example, if the single injection test for an antigen is positive and the provider proceeds to sequential and incremental injection tests, with three additional different dilutions of the same antigen, the provider may report one unit of service for the single injection test code and three units of service for the sequential and incremental test code.

Serial endpoint titration (SET) testing (e.g., intradermal dilution​al testing [IDT]) is reported and reimbursed on a per allergen basis.

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

Description

MPDescriptionPub

An allergy is defined as an acquired hypersensitivity to a substance (allergen) that does not normally cause a reaction. It is essentially a disorder of the immune system that results in an antibody–antigen reaction. The most common manifestations of allergy involve the respiratory tract or the skin. Allergic conditions can cause manifestations such as, but not limited to, eczema, allergic rhinitis, hay fever, bronchial asthma, and urticaria (hives). Severe reaction, such as an anaphylactic response, can result in dyspnea, violent cough, chest constriction, cyanosis, fever, pulse variations, convulsions, and/or collapse.

As the majority of clinically significant environmental, food, and medication allergies are mediated by an immune globulin E (IgE) antibody immune system response, allergy testing aims to identify an IgE-specific response to the allergen in question through in vivo or in vitro methods. In vivo allergy tests are those that are performed directly on the individual; in vitro tests are performed using an individual's serum sample.

In vivo allergy testing is performed to determine an individual's sensitivity to particular allergens and the degree of the reaction. This testing will provide recommendations for changes in the home/work environment and/or evaluate the necessity of medications and/or immunotherapy to control the reactions. Skin-prick testing is the most commonly performed allergy sensitivity test, although the following cutaneous and mucous membrane tests may also be included in an allergy evaluation:

• Skin tests (prick, scratch, intradermal)
• Intradermal testing
• Patch testing
• Photo patch testing
• Photo testing
• Bronchial inhalation challenges
• Food ingestion challenges
• Mucous membrane testing
• Serial endpoint titration (SET) testing (e.g., intradermal dilutional testing [IDT])

In vivo allergy tests must be interpreted in the context of each individual’s specific clinical history; the diagnosis of an allergic disorder cannot be based solely on the result of an in vivo sensitivity test. Allergy is a dynamic physiologic response with multiple contributing variables, including, but not limited to, presence of allergen-specific IgE. Although most individuals who experience symptoms of hypersensitivity on allergen exposure show measurable levels of allergen-specific IgE, some sensitized individuals may be asymptomatic on exposure to the allergen of interest. Skin tests and other in vivo tests are important and recommended in the identification of allergy, but it should be noted that alone they are not sufficient to diagnose allergy.​

All individuals should not necessarily receive the same number of allergy tests. Testing should be patient-specific based on the history, physical examination, and provider's clinical judgement. Per evidence-based guidelines, the number of skin tests (e.g., ≤​70 prick/puncture and 40 intracutaneous tests) for inhalant allergens is justified as an initial diagnostic evaluation. Also, up to 80 patch tests may be required for an allergic contact dermatitis (ACD) diagnosis. Routine annual utilization of a large number of skin tests or tests without a discernable indication would not be indicated. 

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SKIN TESTING

Skin tests (prick, scratch, intradermal) accurately measure an individual's response to certain allergens. A small amount of solution containing different allergens is used. The professional provider either injects or applies the solution to the skin and evaluates the skin reaction. Photo patch testing includes exposing the skin to a dose of ultraviolet light that is sufficient to produce an inflammatory redness of the skin. If the test is positive, a more severe reaction develops at the patch site than on the surrounding skin. 

PATCH TESTING

Patch testing is used to differentiate ACD and irritant contact dermatitis (ICD). Patch testing is the gold standard method of identifying the cause of ACD. A small amount of the suspected allergen is applied to the person's back and evaluated after 48, 72, and 96 hours.

 

PHOTO PATCH TESTING

Photo patch testing is a form of patch testing used when the reaction to the suspected antigen occurs only in the presence of sunlight. It includes exposing the skin to a dose of ultraviolet light that is sufficient to produce an inflammatory redness of the skin. If the test is positive, a more severe reaction develops at the patch site than on the surrounding skin.

 

PHOTO TESTS

Photo tests are used to evaluate skin abnormalities (e.g., itching, blisters, and hives) resulting from exposure to sunlight.

BRONCHIAL INHALATION CHALLENGES

Bronchial inhalation challenges are used to determine if an individual has hyper-responsive airways when skin testing sensitivity results are not consistent with an individual's history. Histamine, methacholine, or allergens may be administered in increasing increments until a response is produced.

FOOD INGESTION CHALLENGES

Food ingestion challenges help diagnose allergies to food. The individual ingests the food to which sensitivity is suspected and is observed and evaluated for allergy symptoms. The individual must undergo a risk evaluation determination to find the food challenge category that describes their risk level (i.e., low risk or high risk). Risk evaluation decisions are based on the same types of data that are evaluated in the early food allergy diagnosis process (e.g., penicillin skin test [PST] results, patient history). Once a risk category is determined, the decision regarding what the most appropriate setting (office, hospital, or short procedure unit) for the oral food challenge can be made.

For the individual in the low-risk category, the settings where injections for allergen immunotherapy are administered should suffice for oral food challenges.

If the challenge is considered high risk (e.g., the individual is asthmatic, the individual has had a previous severe reaction), the challenge should be performed in a more controlled setting where additional interventions to support and reverse anaphylactic shock are available, such as a hospital or short procedure unit.

MUCOUS MEMBRANE TESTING

Conjunctival or nasal challenge testing involves the direct administration of the allergen to the mucosa, to test for suspected localized eye allergy or nasal allergy, respectively. The individual is observed and evaluated for allergy symptoms.

SET TESTING

SET testing is used in conjunction with immunotherapy to determine a starting point for an individual's sensitivity from an IgE standpoint for the allergen (antigen) in question. This procedure involves injecting a series of a very small amount of antigen into the individual's arm. Each injection bump, which is called a wheal, is then measured and recorded in millimeters. The size of the wheal helps the professional provider determine an individual's sensitivity to the allergen and what dosage is needed to safely begin the desensitization process. Generally, it takes three tests (dilutions) per allergen to determine the serial endpoint.

PROVOCATION-NEUTRALIZATION TESTING

Provocation-neutralization testing determines the presence of allergy to foods, inhalants, and environmental chemicals by exposing the individual to test doses of substances that are administered intradermally​, subcutaneously, or sublingually with the goal of either producing or preventing subjective symptoms. There is insufficient evidence to support the effectiveness of sublingual testing (antigens prepared for sublingual administration) and provocation-neutralization testing for the diagnosis and treatment of allergies.​

References

Coding

CPT Procedure Code Number(s)

ICD - 10 Procedure Code Number(s)

ICD - 10 Diagnosis Code Number(s)

HCPCS Level II Code Number(s)

Revenue Code Number(s)

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History