Monday, January 16, 2017

CPT CODE 95004, 86003,86001 95024 - Allergy Testing

Coverage Indications, Limitations, and/or Medical Necessity


Allergy testing is performed to determine a patient's immunologic sensitivity or reaction to particular allergens for the purpose of identifying the cause of the allergic state. It is based on findings during a complete medical and immunologic history, and appropriate physical exam obtained by face-to-face contact with the patient.


Allergy skin testing is a clinical procedure that is used to evaluate an immunologic response to allergenic material. It would not be expected that all patients would receive the same tests or the same number of sensitivity tests. The number and type of antigens used for testing must be chosen judiciously given the patient’s presentation, history, physical findings, and clinical judgment.

To be covered by Medicare, the antigens must meet all of the following criteria:

Skin testing must be performed based on a complete history and physical exam,

Proven efficacy as demonstrated through scientifically valid peer reviewed published medical studies, and

Exist in the patient’s environment with a reasonable probability of exposure

Allergy testing can be broadly subdivided into two methodologies:

In vivo testing (skin tests): this testing correlates the performance and evaluation of selective cutaneous and mucous membrane tests with the patient’s history, physician examination, and other observations.
Percutaneous Testing (scratch, puncture, prick) and is used to evaluate immunoglobulin E (IgE) mediated hypersensitivity. Percutaneous tests require medical supervision, since there is a small but significant risk of anaphylaxis. Overall, skin testing is quick, safe, and cost-effective. It remains the test of choice in most clinical situations where immediate hypersensitivity reactions are suspected.

Percutaneous testing is the usual preferred method for allergy testing. Medicare covers percutaneous (scratch, prick or puncture) testing when IgE-mediated reactions occur with any of the following:


Foods. (Patients present with signs and symptoms such as urticarial, angioedema, or anaphylaxis after ingestion of specific foods. Testing for food allergies in patients who present with wheezing is occasionally required.)

Hymenoptera (stinging insects).

Specific drugs (penicillins, macromolecular agents, enzymes, and egg-containing vaccines). Skin testing is unreliable with other drugs.

Intracutaneous/Intradermal Tests are usually performed when increased sensitivity is the main goal such as when percutaneous tests are negative and there is a strong suspicion of allergen sensitivity. Intradermal tests are injections of small amounts of antigen into the superficial layers of the skin. The usual testing program may include 2 concentrations of an extract: a weaker concentration and a stronger concentration. It would not be expected that 3 or more concentrations of one extract would be medically necessary. Medicare covers intradermal (intracutaneous) testing when IgE-mediated reactions occur to any of the following:


Hymenoptera (stinging insects).

Specific drugs (penicillins and macromolecular agents).

Patch Testing is the gold standard method of identifying the cause of allergic contact dermatitis. This testing is indicated to evaluate a nonspecific dermatitis, pruritus, to differentiate allergic contact dermatitis (ACD) and irritant contact dermatitis (ICD) and determine the causative antigen. It is a diagnostic test reserved for patients with skin eruptions for which a contact allergy source is likely.

The patch test procedure can induce an eczematous reaction in miniature by applying suspect allergens to normal skin, allowing the physician to determine a specific patient allergy. Patch tests are applied to the skin on the patient’s back and left in place for 48 hours. The test is interpreted after 48 hours, and typically once again at 72 or 96 hours, and the reactions are systematically scored and recorded. The patient is then informed and educated regarding specific allergies and avoidance of exposure. Avoidance of the identified allergen(s) is critical to patient improvement and resolution of the dermatitis.

Allergy patch testing is a covered procedure only when used to diagnose allergic contact dermatitis after the following exposures: dermatitis due to detergents, oils and greases, solvents, drugs and medicines in contact with skin, other chemical products, food in contact with skin, plants (except food), cosmetics, metals, rubber additives, other and unspecified. Patch tests may also be used and may be helpful when a distribution and persistence of dermatitis suggests a possible contact allergy, but the exact etiology of the dermatitis is unknown. These allergens are part of a useful, but limited series of 36 allergens. While this series of 36 allergens represents some of the most common contact allergies, there are a significant number of patients who suffer intractable contact dermatitis for which the 36 allergens are inadequate to diagnose their problem. A supplemental series of allergens in this case can enhance accurate diagnosis, patient education, and treatment. This supplemental series is particularly critical in the diagnosis of occupationally induced dermatitis. If another supplemental series of allergens are clinical indicated for an accurate diagnosis, the documentation must support the medically reasonable and necessary use of the additional allergens.

Photo Patch Testing uses two patches, with one of them being irradiated with ultraviolet light half way through the occlusive period. It is indicated to evaluate unique allergies resulting from light exposure. Some chemicals or medications produce an allergic reaction only when exposed to light (usually ultraviolet type A, UVA). Patients who are over-sensitive to light and those with a rash that appears on parts of the body normally exposed to light but that does not appear in areas shielded from the light should have a photo-patch test.

Photo Tests is skin irradiation with a specific range of ultraviolet light. Photo tests are performed for the evaluation of photosensitivity disorders.

Skin Endpoint Titration (SET) Testing or Intradermal Dilutional Testing (IDT) analyzes the highest dilution of a substance that produces a reaction, and may be used to determine the starting dose(s) of allergen immunotherapy.

Delayed Hypersensitivity Skin Testing has been commonly used in three ways: anergy testing, testing for infection with intracellular pathogens, and testing for sensitivity to contact allergens. Accurate testing for contact allergy requires careful attention to technique, and limitation of testing to the specific allergens known to be associated with a contact reaction.

Ophthalmic Mucous Membrane Tests and Direct Nasal Mucous Membrane Tests are rarely indicated. They are allowed when skin testing cannot test allergens.

Ophthalmic mucous membrane tests and direct nasal mucous membrane tests are approved if levels of allergic mediators (such as histamine and tryptase) are measured and a placebo control is performed. This is usually performed in allergy research laboratories. It is also approved in the office setting if the physician is there to observe objective measurement of reactions which might include redness of the eyes, tearing and sneezing.

Inhalation Bronchial Challenge Testing involves the inhalation of agents that can trigger respiratory responses and are often used to evaluate new allergens and/or substantiate the role of allergens in patients with significant symptoms. Results of these tests are ordinarily evaluated by objective measures of pulmonary function and occasionally by characterization of bronchoalveolar lavage samples.
Inhalation bronchial challenge tests should be performed as dose-response assays where in provocation concentration thresholds can be determined on the basis of allergen concentration required to cause a significant decrease in measured pulmonary function.

Inhalation bronchial challenge tests with occupational allergens need to be carefully controlled with respect to dose and duration of exposure. When industrial small molecular weight agents are assessed, tests should be performed under conditions of continuous monitoring of the specific chemical being assessed so as not to exceed the threshold limit level permitted in the workplace.

Ingestion (Oral) Challenge Test involves the administration of sequentially or incrementally larger doses of the test item. The test items may include food or antibiotics. The service is allowed once per patient encounter, regardless of the number of items tested, and includes evaluation of the patient's response to the test items.

Challenge ingestion food testing is a safe and effective technique in the diagnosis of food allergies. This procedure is covered when it is used on an outpatient basis if it is reasonable and necessary for the individual patient. (CMS Pub. 100-03 Medicare National Coverage Determination (NCD)Manual, Chapter 1- Coverage Determinations, Part 2 Section 110.12- Challenge Ingestion Food Testing).

Challenge ingestion food testing is covered for the following indications:
Food allergy, dermatitis

Anaphylactic shock due to adverse food reaction

Allergy to medicinal agents

Allergy to foods

Challenge ingestion food testing has not been proven to be effective in the diagnosis of rheumatoid arthritis, depression, or respiratory disorders. Accordingly, its use in the diagnosis of these conditions is not reasonable and necessary within the meaning of section 1862(a) (1) of the Medicare law, and no program payment is made for this procedure when it is so used. (CMS Pub. 100-03 Medicare National Coverage Determination (NCD)Manual, Chapter 1- Coverage Determinations, Part 2 Section 110.12- Challenge Ingestion Food Testing).

Intracutaneous testing, delayed reaction - more than 6 tests, may be covered but requires additional justification and case-by-case review for the number of tests performed and the medical necessity except when the skin test is used:

Prior to collagen implant therapy, a skin test for collagen sensitivity must be administered and evaluated over a 4 week period. CMS Pub 100-03 Medicare National Coverage Determinations (NCD) Manual, Chapter 1 – Coverage Determinations, Part 4, Section 230.10 – Incontinence Control Devices.

Organ challenge test materials may be applied to the mucosae of the conjunctivae, nares, GI tract, or bronchi. Considerable experience with these methods is required for proper interpretation and analysis. All organ challenge tests should be preceded by a control test with diluent and, if possible, the procedure should be performed on a double blind or at least single-blind basis.

In vitro testing (blood serum analysis): immediate hypersensitivity testing by measurement of allergen-specific serum IgE in the blood serum. They are useful when testing for inhalant allergens (pollens, molds, dust mites, animal danders), foods, insect stings, and other allergens such as drugs or latex, when direct skin testing is impossible due to extensive dermatitis, marked dermatographism, or in children younger than four years of age.

In vitro testing is covered when skin testing is not possible or would be unreliable; or in vitro testing is medically reasonable and necessary as determined by the physician. When in vitro testing is ordered or performed, the medical record must clearly document the indication and why it is being used instead of skin testing.

It is not covered when done in addition to a skin test for the same antigen, except in the case of suspected latex sensitivity, hymenoptera, or nut/peanut sensitivity where both the skin test and the in-vitro test may be performed. The number of tests done, choice of antigens, frequency of repetition and other coverages issues are the same as skin testing.

Testing must be based on a careful history/physical examination which suggests IgE medicated disease. Total Serum IgE is not appropriate in most general allergy testing. Instead, individual IgE tests are performed against a specific antigen.

Special clinical situations in which specific IgE immunoassays are performed against a specific antigen may be appropriate in the following situations:
Patients with extensive dermatitis, severe dermatographism, ichthyosis or generalized eczema that will not make direct skin testing possible.

Patients needing continued use of H-1 blockers (antihistamines), or in the rare patient with persistent unexplained negative histamine control.

Patients who cannot be safely withdrawn from medications that interfere with skin testing, such as long-acting antihistamines, tricyclic antidepressants, beta-blockers, or medications that may put the patient at undue risk if they are discontinued long enough to perform skin tests.

Uncooperative patients with mental or physical impairments.

For evaluation of cross-reactivity between insect venoms (e.g., fire ant, bee, wasp, yellow jacket, hornet).

As adjunctive laboratory testing for disease activity of allergic bronchopulmonary aspergillosis and certain parasitic disease.

To diagnose atopy in small children.

Patients at increased risk for anaphylactic response from skin testing based on clinical history (e.g., when an unusual allergen is not available as a licensed skin test extract), or who have a history of a previous systemic reaction to skin testing.

Patients in who skin testing were equivocal/inconclusive and in vitro testing is required as a confirmatory test.

Total IgE is reasonable and necessary for follow-up of ABPA and to diagnosis atopy in children.

Retesting with the same antigen(s) should rarely be necessary within a three-year period. Exceptions include young children with negative skin tests, or older children and adults with negative skin tests in the face of persistent symptoms. Routine repetition of skin tests is not indicated (i.e., annually) and not covered.


The following tests are considered not medically reasonable and necessary:
Ingestion (Oral) Challenge Food Testing performed by the patient in the home, and not in the office setting, will not be covered.

Provocative Testing for which there is limited or no evidence of validity include the cytotoxic test, the provocation-neutralization procedure, electrodermal diagnosis, applied kinesiology, the "reaginic" pulse test, and chemical analysis of body tissues. Controlled studies for the cytotoxic and provocation-neutralization tests demonstrated that the results are not reproducible and do not correlate with clinical evidence of allergy. Electrodermal diagnosis and applied kinesiology have not been evaluated for efficacy. Similarly, the "reaginic" pulse test and chemical analysis of body tissues for various exogenous chemicals have not been substantiated as valid tests for allergy.

Provocative and neutralization testing and neutralization therapy (Rinkel test) of food allergies (sublingual, intracutaneous and subcutaneous) are excluded from Medicare coverage because available evidence does not show these tests and therapies are effective.

IgG and IgG Subclass Antibody Tests measure allergen-specific IgG and IgG subclasses by using immunoabsorption assays and IgG and IgG subclass antibody tests for food allergy/delayed food allergic symptoms or intolerance to specific foods. These tests are considered experimental and investigational since there is insufficient evidence in the published peer-reviewed scientific literature to support the diagnostic value of these tests.

Antigens for which no clinical efficacy is documented in peer reviewed literature include the following: newsprint, tobacco smoke and leaf, dandelion, orris root, phenol, alcohol, sugar, yeast, grain mill dust, soybean dust (except when the patient has a known exposure to soybean dust such as a food processing plant), honeysuckle, marigold, goldenrod, fiberglass, wool, green tea, or chalk.

Radioallergosorbent test (RAST), fluoroallergosorbent test (FAST), and multiple antigen simultaneous test (MAST) are in vitro techniques for determining whether a patient's serum contains IgE antibodies against specific allergens of clinical importance. As with any allergy testing, the need for such tests is based on the findings during a complete history and physical examination of the patient. These tests are not appropriate in most general allergy testing. Instead, individual IgE tests should be performed against a specific antigen.

ELISA (enzyme-linked immunoaorbent assay) test is another in vitro method of allergy testing for specific IgE antibodies against allergens. It is used to determine in vitro reaction to various foods and relies on lymphocyte blastogenesis in response to certain food antigens.

Quantitative multi-allergen screen is a non-specific screen that does not identify a specific antigen. It is does not have sufficient literature demonstrating clear cut clinical implication. It is a screening tool and therefore not covered by Medicare.

Effective August 5, 1985, cytotoxic leukocyte tests for food allergies are excluded from Medicare coverage because available evidence does not show that these tests are safe and effective. (CMS Pub. 100-03 Medicare National Coverage Determination (NCD) Manual, Chapter 1- Coverage Determinations, Part 2 Section 110.13-Cytotoxic Food Tests).

Effective October 31, 1988, sublingual intracutaneous and subcutaneous provocative and neutralization testing and neutralization therapy for food allergies are excluded from Medicare coverage because available evidence does not show that these tests and therapies are effective. (CMS Pub 100-03 Medicare National Coverage Determinations Manual, Chapter 1- Coverage Determinations, Part 2, Section 110.11 – Food Allergy Testing and Treatment).

The following tests are considered experimental and investigational for allergy testing as these have not been proven to be effective or appropriate for the evaluation and/or management of IgE-mediated allergic reactions. This list is not all inclusive:
Antigen leukocyte cellular antibody (ALCAT) automated food allergy testing

Applied kinesiology or Nambudripad’s allergy elimination test (NAET (i.e., muscle strength testing or measurement after allergen ingestion)

Anti-Fc epsilon receptor antibodies testing

Anti-IgE receptor antibody testing

Blood, urine, or stool micro-nutrient assessments

Candidiasis test

Chemical analysis of body tissues (e.g., hair)

Chlorinated pesticides (serum)

Chronic urticarial index testing

Clifford materials reactivity testing

Complement (total or components)

Complement antigen testing

C-reactive protein

Cytokine and cytokine receptor assay

Cytotoxic testing for environmental or clinical ecological allergy testing (Bryans Test, ACT)

Electrodermal testing or electro-acupuncture

Electromagnetic sensitivity syndrome/disorder (allergy to electricity, electro-sensitivity, electrohypersensitivity, and hypersensitivity to electricity).

Environmental cultures and chemicals

Eosinophil cationic protein (ECP) test

Food immune complex assay (FICA) or food allergenic extract immunotherapy

General immune system assessments

Immune complex assay

Immunoglobulin G (IgG) testing for allergy


Leukocyte antibodies testing

Leukocyte histamine release test (LHRT)/basophil histamine release test

Lymphocytes (B or T subsets)

Lymphocyte function assay

Mediator release test (MRT) or the LEAP program

Metabolic assessments

Multiple chemical sensitivity syndrome (a.k.a., idiopathic environmental intolerance (IEI), clinical ecological illness, clinical ecology, environmental illness, chemical AIDS, environmental/chemical hypersensitivity disease, total allergy syndrome, cerebral allergy, 20th century disease)

Prausnitz-Kustner or P-K testing - passive cutaneous transfer test

Pulse response test

Qualification of nutritional assessments

Rebuck skin window test

Secretory IgA (salvia)

Sage Complement Antigen Test

Specific Immunoglobulin (IgG) (e.g., by Radioallergosorbent (RAST) or Enzyme-linked immunosorbent assay (ELISA)

Sublingual provocative neutralization testing and treatment with hormones.

Total serum IgG, immunoglobulin A (IgA) and immunoglobulin M (IgM)

Venom blocking antibodies

Volatile chemical panels (blood testing for chemicals)

Live Cell Analysis

Passive Transfer

Cytotoxic Food Testing

Routine allergy re-testing does not meet the definition of medically necessity according to the practice parameters and recommendations from the American College of Allergy, Asthma, and Immunology (ACAAI), the American Academy of Allergy, Asthma, and Immunology (AAAAI), and the Joint Council of Allergy, Asthma, and Immunology (JCAAI).


Group 1 Paragraph: Allergy Testing - Covered

Group 1 Codes:

82785 Assay of ige

86003 Allergen specific ige

95004 Percut allergy skin tests

95017 Perq & icut allg test venoms

95018 Perq&ic allg test drugs/biol

95024 Icut allergy test drug/bug

95027 Icut allergy titrate-airborn

95028 Icut allergy test-delayed

95044 Allergy patch tests

95052 Photo patch test

95056 Photosensitivity tests

95060 Eye allergy tests

95065 Nose allergy test

95070 Bronchial allergy tests

95071 Bronchial allergy tests

95076 Ingest challenge ini 120 min

95079 Ingest challenge addl 60 min

Group 2 Paragraph: Allergy Testing Non-covered

Group 2 Codes:

86001 Allergen specific igg

86005 Allergen specific ige

ICD-10 Codes that Support Medical Necessity

Group 1 Paragraph: Note: Diagnosis codes must be coded to the highest level of specificity.

Allergy Testing 95004, 95017, 95018, 95024, 95027

For codes in the table below that requires a 7th character: letter A initial encounter, D subsequent encounter or S sequela may be used.

Group 1Codes


B44.81 Allergic bronchopulmonary aspergillosis

H10.11 Acute atopic conjunctivitis, right eye

H10.12 Acute atopic conjunctivitis, left eye

H10.13 Acute atopic conjunctivitis, bilateral

H10.31 Unspecified acute conjunctivitis, right eye

H10.32 Unspecified acute conjunctivitis, left eye

H10.33 Unspecified acute conjunctivitis, bilateral

H10.411 Chronic giant papillary conjunctivitis, right eye

H10.412 Chronic giant papillary conjunctivitis, left eye

H10.413 Chronic giant papillary conjunctivitis, bilateral

H10.44 Vernal conjunctivitis

H10.45 Other chronic allergic conjunctivitis

H16.261 Vernal keratoconjunctivitis, with limbar and corneal involvement, right eye

H16.262 Vernal keratoconjunctivitis, with limbar and corneal involvement, left eye

H16.263 Vernal keratoconjunctivitis, with limbar and corneal involvement, bilateral

H65.01 Acute serous otitis media, right ear

H65.02 Acute serous otitis media, left ear

H65.03 Acute serous otitis media, bilateral

H65.04 Acute serous otitis media, recurrent, right ear

H65.05 Acute serous otitis media, recurrent, left ear

H65.06 Acute serous otitis media, recurrent, bilateral

H65.21 Chronic serous otitis media, right ear

H65.22 Chronic serous otitis media, left ear

H65.23 Chronic serous otitis media, bilateral

H65.411 Chronic allergic otitis media, right ear

H65.412 Chronic allergic otitis media, left ear

H65.413 Chronic allergic otitis media, bilateral

H65.491 Other chronic nonsuppurative otitis media, right ear

H65.492 Other chronic nonsuppurative otitis media, left ear

H65.493 Other chronic nonsuppurative otitis media, bilateral

H66.91 Otitis media, unspecified, right ear

H66.92 Otitis media, unspecified, left ear

H66.93 Otitis media, unspecified, bilateral

J01.00 Acute maxillary sinusitis, unspecified

J01.01 Acute recurrent maxillary sinusitis

J01.10 Acute frontal sinusitis, unspecified

J01.11 Acute recurrent frontal sinusitis

J01.20 Acute ethmoidal sinusitis, unspecified

J01.21 Acute recurrent ethmoidal sinusitis

J01.30 Acute sphenoidal sinusitis, unspecified

J01.31 Acute recurrent sphenoidal sinusitis

J01.40 Acute pansinusitis, unspecified

J01.41 Acute recurrent pansinusitis

J01.80 Other acute sinusitis

J01.81 Other acute recurrent sinusitis

J01.90 Acute sinusitis, unspecified

J01.91 Acute recurrent sinusitis, unspecified

J04.0 Acute laryngitis

J04.30 Supraglottitis, unspecified, without obstruction

J04.31 Supraglottitis, unspecified, with obstruction

J05.0 Acute obstructive laryngitis [croup]

J30.0 Vasomotor rhinitis

J30.1 Allergic rhinitis due to pollen

J30.2 Other seasonal allergic rhinitis

J30.5 Allergic rhinitis due to food

J30.81 Allergic rhinitis due to animal (cat) (dog) hair and dander

J30.89 Other allergic rhinitis

J31.0 Chronic rhinitis

J31.1 Chronic nasopharyngitis

J31.2 Chronic pharyngitis

J32.0 Chronic maxillary sinusitis

J32.1 Chronic frontal sinusitis

J32.2 Chronic ethmoidal sinusitis

J32.3 Chronic sphenoidal sinusitis

J33.0 Polyp of nasal cavity

J33.8 Other polyp of sinus

J34.3 Hypertrophy of nasal turbinates

J34.81 Nasal mucositis (ulcerative)

J34.89 Other specified disorders of nose and nasal sinuses

J35.01 Chronic tonsillitis

J35.02 Chronic adenoiditis

J35.03 Chronic tonsillitis and adenoiditis

J35.1 Hypertrophy of tonsils

J35.2 Hypertrophy of adenoids

J35.3 Hypertrophy of tonsils with hypertrophy of adenoids

J45.20 Mild intermittent asthma, uncomplicated

J45.21 Mild intermittent asthma with (acute) exacerbation

J45.22 Mild intermittent asthma with status asthmaticus

J45.30 Mild persistent asthma, uncomplicated

J45.31 Mild persistent asthma with (acute) exacerbation

J45.32 Mild persistent asthma with status asthmaticus

J45.40 Moderate persistent asthma, uncomplicated

J45.41 Moderate persistent asthma with (acute) exacerbation

J45.42 Moderate persistent asthma with status asthmaticus

J45.50 Severe persistent asthma, uncomplicated

J45.51 Severe persistent asthma with (acute) exacerbation

J45.52 Severe persistent asthma with status asthmaticus

J45.901 Unspecified asthma with (acute) exacerbation

J45.902 Unspecified asthma with status asthmaticus

J45.909 Unspecified asthma, uncomplicated

J45.991 Cough variant asthma

J45.998 Other asthma

K29.30 Chronic superficial gastritis without bleeding

K29.60 Other gastritis without bleeding

L20.0 Besnier's prurigo

L20.81 Atopic neurodermatitis

L20.82 Flexural eczema

L20.84 Intrinsic (allergic) eczema

L20.89 Other atopic dermatitis

L23.9 Allergic contact dermatitis, unspecified cause

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