DESCRIPTION
Allergy testing, evaluations, and immunotherapy are eligible for coverage according to the schedule of covered services in plan documents. Testing or treatment methods not considered as standard medical procedures are not eligible for coverage.
CODING INFORMATION
ICD-10 Codes that may support medical necessity:
D69.0 Allergic purpura
H10.401 – H10.409 Unspecified chronic conjunctivitis
H10.421 – H10.429 Simple chronic conjunctivitis
H10.44 Vernal conjunctivitis
H16.261 – H16.269 Vernal keratoconjunctivitis, with limbar and corneal
H10.411 – H10.419 Chronic giant papillary conjunctivitis
H10.45 Other chronic allergic conjunctivitis
H10.9 Unspecified conjunctivitis
J30.0 – J30.9 Vasomotor and allergic rhinitis
J31.0 – J31.2 Chronic rhinitis, nasopharyngitis and pharyngitis
J32.0 – J32.9 Chronic sinusitis
J33.0 – J33.9 Nasal polyp
J45.20 – J45.998 Asthma
K52.2 Allergic and dietetic gastroenteritis and colitis
K52.89 Other specified noninfective gastroenteritis and colitis
K52.9 Noninfective gastroenteritis and colitis, unspecified
L20.0 – L20.9 Atopic dermatitis
L22 Diaper dermatitis
L23.0 – L23.9 Allergic contact dermatitis
L24.0 – L24.9 Irritant contact dermatitis
L25.0 – L25.9 Unspecified contact dermatitis
L27.0 – L27.9 Dermatitis due to substances taken internally
L29.8 Other pruritus
L29.9 Pruritus, unspecified
L30.0 – L30.9 Other and unspecified dermatitis
L50.0 Allergic urticaria
L50.1 Idiopathic urticaria
L50.6 Contact urticaria
L50.8 Other urticaria
L50.9 Urticaria, unspecified
L56.4 Polymorphous light eruption
T50.905A-T50.905S Adverse effect of unspecified drugs, medicaments and biological substances
T50.995A-T50.905S Adverse effect of other drugs, medicaments and biological substances
T78.00xA-T78.1xxS Anaphylactic reaction due to food
ALLERGY TESTING / IMMUNOTHERAPY
POLICY/CRITERIA
A. The following allergy tests are covered benefits:
1. IgE Specific Antibody (e.g., RAST, micro-Elisa, immunocap) if clinically indicated for history of severe urticaria, hives, or severe allergy, when skin testing is inappropriate.
2. Skin tests (scratch, intradermal, pricks)
3. Patch application tests
4. Drug Provocation testing
5. Skin Endpoint Titration (SET). Skin endpoint titration is effective for quantifying patient sensitivity and for providing a safe starting dose for immunotherapy. SET has not been shown to be an effective guide to a final therapeutic dose.
B. The following services have not been proven to be effective in diagnosing and/or treating allergies, and are not covered benefits:
1. Cytotoxicity testing (Bryan’s test)
2. Urine autoinjection (autogenous urine immunization)
3. Provocation testing and neutralization therapy for food allergy (intracutaneous, subcutaneous or sublingually). Also called Intracutaneous Progressive Dilution Food Test (IPDFT).
4. Antigen leukocyte cellular antibody test (ALCAT) for all indications including but not limited to testing for food allergies or intolerance (chemical sensitivities) and as a tool to establish elimination diets.
5. Electrodermal testing or electro-acupuncture*
6. Applied kinesiology or muscle strength testing of allergies
7. Reaginic pulse testing or pulse testing for allergies
8. Total serum immunoglobulin G (IgG), immunoglobulin A (IgA) and immunoglobulin M (IgM)
9. Testing of specific IgG antibody (e.g., by RAST or ELISA testing)
10. Lymphocyte subset counts
11. Lymphocyte function assay
12. Lymphocyte transformation test (LTT), also known as lymphocyte proliferation test and metal ion testing for metal-induced hypersensitivity response.
13. Cytokine, cytokine receptor assay and Th1/Th2 cytokine ratio
14. Natural Killer (NK) cell assay or activity
15. Food immune complex assay (FICA)
16. Leukocyte histamine release testing
17. Body chemical analysis
18. Sublingual immunotherapy (SLIT) as an alternative way to treat allergies without injections. SLIT is not FDA approved in the United States
*Note: Acupuncture may be covered with a rider for some commercial plans
Allergic contact dermatitis
Includes: allergic contact eczema
Excludes: allergy NOS (T78.4), dermatitis (of): NOS (L30.9), contact NOS (L25.9), due to substances taken internally (L27.-), eyelid (H01.1), irritant contact (L24.-), perioral (L71.0), eczema of external ear (H60.5),radiation-related disorders of the skin and subcutaneous tissue (L55-L59)
L23.0 Allergic contact dermatitis due to metals Chromium, Nickel
L23.1 Allergic contact dermatitis due to adhesives
L23.2 Allergic contact dermatitis due to cosmetics
L23.3 Allergic contact dermatitis due to drugs in contact with skin Use additional external cause code (Chapter XX), if desired, to identify drug.
Excludes: allergic reaction NOS due to drugs (T88.7), dermatitis due to ingested drugs and medicaments (L27.0-L27.1)
L23.4 Allergic contact dermatitis due to dyes
L23.5 Allergic contact dermatitis due to other chemical products Cement, Insecticide, Plastic, Rubber
L23.6 Allergic contact dermatitis due to food in contact with skin Excludes: dermatitis due to ingested food (L27.2)
L23.7 Allergic contact dermatitis due to plants, except food
L23.8 Allergic contact dermatitis due to other agents
L23.9 Allergic contact dermatitis, unspecified cause Allergic contact eczema NOS
L24.- Irritant contact dermatitis Includes: irritant contact eczema
Excludes: allergy NOS (T78.4), dermatitis (of): NOS (L30.9), allergic contact (L23.-), contact NOS (L25.9), due to substances taken internally (L27.-), eyelid (H01.1), perioral (L71.0), eczema of external ear (H60.5), radiation-related disorders of the skin and subcutaneous tissue (L55-L59)
L24.0 Irritant contact dermatitis due to detergents
L24.1 Irritant contact dermatitis due to oils and greases
L24.2 Irritant contact dermatitis due to solvents Solvents: chlorocompound, cyclohexane, ester, glycol, hydrocarbon, ketones
L24.3 Irritant contact dermatitis due to cosmetics
L24.4 Irritant contact dermatitis due to drugs in contact with skin Use additional external cause code (Chapter XX), if desired, to identify drug.
Excludes: allergic reaction NOS due to drugs (T88.7), dermatitis due to ingested drugs and medicaments (L27.0-L27.1)
L24.5 Irritant contact dermatitis due to other chemical products Cement, Insecticide
L24.6 Irritant contact dermatitis due to food in contact with skin Excludes: dermatitis due to ingested food (L27.2)
L24.7 Irritant contact dermatitis due to plants, except food
L24.8 Irritant contact dermatitis due to other agents Dyes
L24.9 Irritant contact dermatitis, unspecified cause Irritant contact eczema NOS
L25.- Unspecified contact dermatitis
Includes: unspecified contact eczema
Excludes: allergy NOS (T78.4), dermatitis (of): NOS (L30.9), allergic contact (L23.-), due to substances taken internally (L27.-), eyelid (H01.1), irritant contact (L24.-), perioral (L71.0), eczema of external ear (H60.5), radiation-related disorders of the skin and subcutaneous tissue (L55-L59)
L25.0 Unspecified contact dermatitis due to cosmetics
L25.1 Unspecified contact dermatitis due to drugs in contact with skin Use additional external cause code (Chapter XX), if desired, to identify drug.
Excludes: allergic reaction NOS due to drugs (T88.7), dermatitis due to ingested drugs and medicaments (L27.0-L27.1)
L25.2 Unspecified contact dermatitis due to dyes
L25.3 Unspecified contact dermatitis due to other chemical products Cement, Insecticide
L25.4 Unspecified contact dermatitis due to food in contact with skin Excludes: dermatitis due to ingested food (L27.2)
L25.5 Unspecified contact dermatitis due to plants, except food
L25.8 Unspecified contact dermatitis due to other agents
L25.9 Unspecified contact dermatitis, unspecified cause Contact: dermatitis (occupational) NOS, eczema (occupational) NOS
R68.- Other general symptoms and signs