Allergy and Hypersensitivity - Medical Clinical Policy Bulletins

Information in the [brackets] below has been added for clarification purposes. &nbspCodes requiring a 7th character are represented by “+”:

Allergy testing:

Epicutaneous (scratch, prick, or puncture):

CPT codes covered if selection criteria are met:

95004 Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, including test interpretation and report by a physician, specify number of tests [not covered AFTER allergen immunotherapy] 95017 Allergy testing, any combination of percutaneous (scratch, puncture, prick) and intracutaneous (intradermal), sequential and incremental, with venoms, immediate type reaction, including test interpretation and report, specify number of tests [not covered AFTER allergen immunotherapy] 95018 Allergy testing, any combination of percutaneous (scratch, puncture, prick) and intracutaneous (intradermal), sequential and incremental, with drugs or biologicals, immediate type reaction, including test interpretation and report, specify number of tests [not covered AFTER allergen immunotherapy]

CPT codes not covered for indications listed in the CPB:

0165U Peanut allergen-specific IgE and quantitative assessment of 64 epitopes using enzyme-linked immunosorbent assay (ELISA), blood, individual epitope results and interpretation [VeriMAP Peanut Dx] 0178U Peanut allergen-specific quantitative assessment of multiple epitopes using enzyme-linked immunosorbent assay (ELISA), blood, report of minimum eliciting exposure for a clinical reaction

ICD-10 codes covered if selection criteria are met:

J30.1 – J30.9 Allergic rhinitis L20.84 Intrinsic (allergic) eczema L25.4 Unspecified contact dermatitis due to food in contact with skin L27.2 Dermatitis due to ingested food L50.0 Allergic urticaria T50.995+ Adverse effect of other drugs, medicaments and biological substances T63.001+ – T63.94x+ Toxic effect of contact with venomous animals and plants T78.00+ – T78.09+ Anaphylactic shock due to adverse food reaction T78.1+ Other adverse food reactions, not elsewhere classified

Intradermal (Intracutaneous) when IgE-mediated reactions occur:

CPT codes covered if selection criteria are met:

95024 Intracutaneous (intradermal) tests with allergenic extracts, immediate type reaction, including test interpretation and report by a physician, specify number of tests 95027 Intracutaneous (intradermal) tests, sequential and incremental, with allergenic extracts for airborne allergens, immediate type reaction, including test interpretation and report by a physician, specify number of tests 95028 Intracutaneous (intradermal) tests with allergenic extracts, delayed type reaction, including reading, specify number of tests

ICD-10 codes covered if selection criteria are met:

Skin Endpoint Titration (SET):

CPT codes covered if selection criteria are met:

95027 Intracutaneous (intradermal) tests, sequential and incremental, with allergenic extracts for airborne allergens, immediate type reaction, including test interpretation and report by a physician, specify number of tests

ICD-10 codes covered if selection criteria are met:

J30.1 – J30.9 Allergic rhinitis T63.001+ – T63.94x+ Toxic effect of contact with venomous animals and plants Z91.030 – Z91.038 Insect allergy status

Skin Patch Testing:

CPT codes covered if selection criteria are met:

95044 Patch or application tests(s) (specify number of tests)

ICD-10 codes covered if selection criteria are met:

L20.84 Intrinsic (allergic) eczema L23.0 – L23.9 Allergic contact dermatitis L50.0 Allergic urticaria

ICD-10 codes not covered for indications listed in the CPB:

K52.21 Food protein-induced enterocolitis syndrome K58.0 – K58.9 Irritable bowel syndrome

Photo Patch Test:

CPT codes covered if selection criteria are met:

95052 Photo patch test(s) (specify number of tests)

ICD-10 codes covered if selection criteria are met:

L56.1 Drug photoallergic response L56.2 Photocontact dermatitis [berloque dermatitis] L56.3 Solar urticaria

Photo Tests:

CPT codes covered if selection criteria are met:

95056 Photo tests

ICD-10 codes covered if selection criteria are met:

L56.1 Drug photoallergic response L56.2 Photocontact dermatitis [berloque dermatitis] L56.3 Solar urticaria

Bronchial Challenge Test:

CPT codes covered if selection criteria are met:

95070 Inhalation bronchial challenge testing (not including necessary pulmonary function tests); with histamine, methacholine, or similar compounds 95071 with antigens or gases, specify

Other CPT codes related to the CPB:

94150 Vital capacity, total (separate procedure) 94200 Maximum breathing capacity, maximum voluntary ventilation 94621 Pulmonary stress testing; complex (including measurements of CO2 production, O2 uptake, and electrocardiographic recordings) 94680 Oxygen uptake, expired gas analysis; rest and exercise, direct, simple 94681 including CO2 output, percentage oxygen extracted 94690 rest, indirect (separate procedure) 94726 Plethysmography for determination of lung volumes and, when performed, airway resistance 94729 Diffusing capacity (eg, carbon monoxide, membrane) (List separately in addition to code for primary procedure) 94770 Carbon dioxide, expired gas determination by infrared analyzer

HCPCS codes covered if selection criteria are met:

J7674 Methacholine chloride administered as inhalation solution through a nebulizer, per 1mg

ICD-10 codes covered if selection criteria are met:

J45.20 – J45.998 Asthma J67.0 – J67.9 Hypersensitivity pneumonitis due to organic dust J82 Pulmonary eosinophilia, not elsewhere classified

Exercise Challenge Testing:

CPT codes covered if selection criteria are met:

94010 Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation 94060 Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration 94070 Bronchospasm provocation evaluation, multiple spirometric determinations as in 94010, with administered agents (e.g., antigen(s), cold air, methacholine) 94150 Vital capacity, total (separate procedure) 94200 Maximum breathing capacity, maximum voluntary ventilation 94240 Functional residual capacity or residual volume; helium method, nitrogen open circuit method, or other method 94350 Determination of maldistribution of inspired gas; multiple breath nitrogen washout curve including alveolar nitrogen or helium equilibration time 94360 Determination of resistance to airflow, oscillatory or plethysmographic methods 94375 Respiratory flow volume loop 94617 Exercise test for bronchospasm, including pre- and post-spirometry, electrocardiographic recording(s), and pulse oximetry 94618 Pulmonary stress testing (eg, 6-minute walk test), including measurement of heart rate, oximetry, and oxygen titration, when performed 94621 Pulmonary stress testing; complex (including measurements of CO2 production, O2uptake, and electrocardiographic recordings) 94680 Oxygen uptake, expired gas analysis; rest and exercise, direct, simple 94681 including CO2 output, percentage oxygen extracted 94690 rest, indirect (separate procedure) 94720 Carbon monoxide diffusing capacity (e.g., single breath, steady state) 94770 Carbon dioxide, expired gas determination by infrared analyzer 96419 Exercise test for bronchospasm, including pre- and post-spirometry and pulse oximetry; without electrocardiographic recording(s)

HCPCS codes covered if selection criteria are met:

J7674 Methacholine chloride administered as inhalation solution through a nebulizer, per 1 mg

ICD-10 codes covered if selection criteria are met:

J45.990 Exercise induced bronchospasm

Ingestion (Oral) Challenge Test:

CPT codes covered if selection criteria are met:

95076 Ingestion challenge test (sequential and incremental ingestion of test items, eg, food, drug or other substance); initial 120 minutes of testing 95079 each additional 60 minutes of testing (list separately in addition to code for primary procedure)

ICD-10 codes covered if selection criteria are met:

L27.2 Dermatitis due to ingested food T50.995+ Adverse effect of other drugs, medicaments and biological substances T78.00+ – T78.1+ Anaphylactic shock due to adverse food reaction T78.1+ Other adverse food reactions, not elsewhere classified Z88.0 – Z88.9 Allergy status to drugs, medicaments and biological substances

RAST, MAST, FAST, ELISA, ImmunoCAP when percutaneous testing of IgE-mediated allergies cannot be done :

CPT codes covered if selection criteria are met:

83516 Immunoassay for analyte other than infectious agent antibody or infectious agent antigen, qualitative or semiquantitative; multiple step method 83518 single step method (e.g., reagent strip) 83519 Immunoassay, analyte quantitative; by radiopharmaceutical technique (e.g., RIA) 83520 not otherwise specified 86003 Allergen specific IgE; quantitative or semi-quantitative, each allergen [covered for up to 40 in vitro IgE antibody tests for inhalant allergies and 12 tests for food and other allergies] 86005 qualitative, multi-allergen screen (dipstick, paddle or disk) [covered for up to 40 in vitro IgE antibody tests for inhalant allergies and 12 tests for food and other allergies] 86008 Allergen specific IgE; quantitative or semiquantitative, recombinant or purified component, each [covered for up to 40 in vitro IgE antibody tests for inhalant allergies and 12 tests for food and other allergies]

ICD-10 codes covered if selection criteria are met:

B44.81 Allergic bronchpulmonary aspergillosis B65.0 – B83.9 Helminthiases [parasitic diseases] B85.0 – B89 Pediculosis, acariasis and other infestations [parasitic diseases] F43.0 Acute stress reaction [uncooperative patients] F70 – F79 Intellectual disabilities [uncooperative patients] F84.0 – F84.9 Pervasive developmental disorders [uncooperative patients] F90.0 – F90.9 Attention-deficit hyperactivity disorders [uncooperative patients] F91.0 – F91.9 Conduct disorders [uncooperative patients] J30.1 – J30.9 Allergic rhinitis L20.0 – L30.9 Dermatitis and eczema L50.0 Allergic urticaria L50.3 Dermatographic urticarial [dermatographism] L85.0 Acquired ichthyosis Q80.0 – Q80.9 Congenital ichthyosis T50.995+ Adverse effect of other drugs, medicaments and biological substances T63.001+ – T63.94x+ Toxic effect of contact with venomous animals and plants T78.00+ – T78.09+ Anaphylactic shock due to adverse food reaction T78.1+ Other adverse food reactions, not elsewhere classified [except Alpha gal allergy testing for meat allergy] T88.6xx+ Anaphylactic reaction due to adverse effect of correct drug or medicament properly administered [risk of anaphylaxis from skin testing]

Total Serum IgE:

CPT codes covered if selection criteria are met:

82785 Gammaglobulin; IgE

ICD-10 codes covered if selection criteria are met:

B44.81 Allergic bronchopulmonary aspergillosis

Lymphocyte transformation tests:

CPT codes covered if selection criteria are met:

86353 Lymphocyte transformation, mitogen (phytomitogen) or antigen induced blastogenesis [not covered for in-vitro metal allergy testing]

ICD-10 codes covered if selection criteria are met:

B37.0 Candidal stomatitis B37.83 Candidal cheilitis C37.0 Malignant neoplasm of thymus D15.0 Benign neoplasm of thymus D81.0 – D81.9 Combined immunodeficiencies D82.0 Wiskott-Alrich syndrome D82.1 DiGeorge’s syndrome D83.0 – D83.9 Common variable immunodeficiency T56.7+ Toxic effects of beryllium and its compounds

Alpha-gal allergy (meat allergy) testing:

CPT codes covered if selection criteria are met:

86003 Allergen specific IgE; quantitative or semiquantitative, crude allergen extract, each

ICD-10 codes covered if selection criteria are met:

L50.0 – L50.9 Urticaria T78.2XXA – T78.2XXS Anaphylactic shock, unspecified T78.3XXA – T78.3XXS Angioneurotic edema T80.51XA – T80.59XS Anaphylactic reaction due to serum R10.0 – R10.13,
R10.3 – R10.9 Abdominal pain R11.10 – R11.14 Vomiting R55 Syncope and collapse Z91.018 Allergy to other foods [meat allergy]

Tests considered experimental and investigational for routine allergy testing:

CPT codes not covered for indications listed in the CPB:

Basophil activation test (BAT), Genetic testing for food allergy, Lymphocyte or basophil phenotyping for food allergy, infinite allergy lab’s fast allergy sensitivity test (FAST) panel – no specific code 82784 Gammaglobulin (immunoglobulin) IgA, IgD, IgG, IgM, each 82787 Gammaglobulin (immunoglobulin); immunoglobulin subclasses (eg, IgG1, 2, 3, or 4), each [not covered for IgG4 testing] 84238 Receptor assay; non-endocrine (specify receptor) [cytokine and cytokine assay] 84600 Volatiles (eg, acetic anhydride, diethylether) 86001 Allergen specific IgG quantitative or semi-quantitative, each allergen 86003 Allergen specific IgE; quantitative or semiquantitative, crude allergen extract, each. [testing for food-specific IgE to identify food triggers of FPIES] 86015 Actin (smooth muscle) antibody (ASMA), each 86021 Antibody identification; leukocyte antibodies 86036 Antineutrophil cytoplasmic antibody (ANCA); screen, each antibody 86037 titer, each antibody 86140 C-reactive protein 86160 Complement; antigen, each component 86161 functional activity, each component 86162 total hemolytic (CH50) 86243 Fc receptor 86332 Immune complex assay 86343 Leukocyte histamine release test (LHR) 86352 Cellular function assay involving stimulation (eg, mitogen or antigen) and detection of biomarker (EG, ATP) [anti-IgE receptor antibody testing] 86485 Skin test; candida 86628 Antibody; candida 88184 Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; first marker [anti-IgE receptor antibody testing] 88185 each additional marker (List separately in addition to code for first marker) [anti-IgE receptor antibody testing] 88341 Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure) 88342 Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure 88344 Immunohistochemistry or immunocytochemistry, per specimen; each multiplex antibody stain procedure 88346 Immunofluorescence, per specimen; initial single antibody stain procedure 95060 Ophthalmic mucous membrane tests 95065 Direct nasal mucous membrane test 95831 Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk 95832 hand, with or without comparison with normal side 95833 total evaluation of body, excluding hands 95834 total evaluation of body, including hands

HCPCS codes not covered for indications listed in the CPB:

K1026 Mechanical allergen particle barrier/inhalation filter, cream, nasal, topical

Mediator Release Test and Cytotoxic food testing (Bryans Test, ACT):

CPT codes not covered for indications listed in the CPB:

Allergenex testing:

CPT codes not covered for indications listed in the CPB:

Allergenex testing – no specific code:

ICD-10 codes not covered for indications listed in the CPB:

F90.0 – F90.9 Attention-deficit hyperactivity disorders G43.001 – G43.919 Migraine G44.001 – G44.89 Other headache syndromes J30.1 – J30.9 Allergic rhinitis J31.0 – J31.2 Chronic rhinitis, nasopharyngitis and pharyngitis J32.0 – J32.9 Chronic sinusitis K21.0 – K21.9 Gastro-esophageal reflux disease K50.00 – K50.919 Crohn’s disease [regional enteritis] K51.00 – K51.919 Ulcerative colitis K52.21 Food protein-induced enterocolitis syndrome K58.0 – K58.9 Irritable bowel syndrome L20.0 – L30.9 Dermatitis and eczema L50.0 – L50.9 Urticaria M05.00 – M14.89 Inflammatory polyarthropathies M79.0 – M79.5 Other and unspecified soft tissue disorders, not elsewhere classified N95.1 Menopausal and female climacteric states R53.0 – R53.83 Malaise and fatigue R04.0 – R04.1, R06.5 – R06.7, R06.89, R07.0, R09.81 – R09.89, R19.6, R22.0 – R22.1, R47.01 – R47.9, R48.0 – R48.9, R49.0 – R49.9, R51, R68.84 Symptoms and signs involving the head and neck T78.1xxA – T78.1xxS Other adverse food reactions, not elsewhere classified

There is no specific code for Cliffords Material Reactivity Testing:

Allergy immunotherapy:

CPT codes covered if selection criteria are met:

95115 – 95170, 95199 Professional services for allergen immunotherapy (for rapid desensitization see below) [except home administration] [not covered for intradermal grass pollen immunotherapy] [not covered for intranasal immunotherapy]

CPT codes not covered for indications listed in the CPB:

Oral immunotherapy – no specific code:

97810 – 97814 Acupuncture

HCPCS codes covered if selection criteria are met:

J0171 Injection, adrenalin, epinephrine, 0.1 mg

Other HCPCS codes related to the CPB:

J2357 Injection, omalizumab, 5 mg

ICD-10 codes covered if selection criteria are met:

H10.10 – H10.13 Acute atopic conjunctivitis H10.44 Vernal conjunctivitis H10.45 Other chronic allergic conjunctivitis J30.1 – J30.9 Allergic rhinitis J45.20 – J45.998 Asthma [covered for allergic (extrinsic)] [not covered for intrinsic (non-allergic)] L20.89 Other atopic dermatitis [dust mite] T63.001+ – T63.94x+ Toxic effect of contact with venomous animals and plants Z91.030 – Z91.038 Insect allergy status [bees, hornets, wasps, and fire ants]

ICD-10 codes not covered for indications listed in the CPB:

G43.001 – G43.919 Migraine L25.4 Unspecified contact dermatitis due to food in contact with skin L27.2 Dermatitis due to ingested food L50.8 Other urticaria [chronic] T78.3+ Angioneurotic edema

Other Treatments:

Rapid desensitization:

CPT codes covered if selection criteria are met:

95180 Rapid desensitization procedure, each hour (e.g., insulin, penicillin, equine serum)

ICD-10 codes covered if selection criteria are met:

J30.0 – J30.9 Allergic rhinitis S00.06XA – S00.06XS, S00.261A – S00.269S, S00.36xA – S00.36xS, S00.461A – S00.469S, S00.561A – S00.562S, S00.86xA – S00.86xS, S00.96xA – S00.96xS, S10.16XA – S10.16XS, S10.86xA – S10.86xS, S10.96xA – S10.96xS, S20.161A – S20.169S, S20.361A – S20.369S, S20.461A – S20.469S, S20.96XA – S20.96XS, S30.860A – S30.867S, S40.261A – S40.269S, S40.861A – S40.869S, S50.361A – S50.369S, S50.861A – S50.869S, S60.361A – S60.369S, S60.460A – S60.469S, S60.561A – S60.569S, S60.861A – S60.869S, S70.261A – S70.269S, S70.361A – S70.369S, S80.261A – S80.269S, S80.861A – S80.869S, S90.461A – S90.466S, S90.561A – S90.569S, S90.861A – S90.869S Insect bites T36.0X1A – T50.996S Poisoning by, adverse effect of and underdosing of drugs, medicaments and biologic substances T63.421A – T63.484S Toxic effect of venom of other arthropod Z88.0 – Z88.9 Allergy status to drugs, medicaments and biological substances Z91.030 – Z91.038 Allergy to insects

Chemical cautery of nasal mucosa:

CPT codes not covered for indications listed in the CPB:

Chemical cautery of nasal mucosa – no specific code:

ICD-10 codes not covered for indications listed in the CPB:

J30.1 – J30.9 Allergic rhinitis

Subcutaneous or Intramuscular (IM) steroids:

Other CPT codes related to the CPB:

96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

HCPCS codes not covered if selection criteria are met:

J0702 Injection, betamethasone acetate 3mg and betamethasone sodium phosphate 3mg J1020 Injection, methylprednisolone acetate, 20 mg J1030 Injection, methylprednisolone acetate, 40 mg J1040 Injection, methylprednisolone acetate, 80 mg J1094 Injection, dexamethasone acetate, 1 mg J1100 Injection, dexamethasone sodium phosphate, 1mg J1700 Injection, hydrocortisone acetate, up to 25 mg J1710 Injection, hydrocortisone sodium phosphate, up to 50 mg J1720 Injection, hydrocortisone sodium succinate, up to 100 mg J2650 Injection, prednisolone acetate, up to 1 ml J2920 Injection, methylprednisolone sodium succinate, up to 40 mg J2930 Injection, methylprednisolone sodium succinate, up to 125 mg J3300 Injection, triamcinolone acetonide, preservative free, 1 mg J3301 Injection, triamcinolone acetonide, not otherwise specified, 10 mg J3302 Injection, triamcinolone diacetate, per 5mg J3303 Injection, triamcinolone hexacetonide, per 5mg

ICD-10 codes not covered if selection criteria are met:

J01.00 – J01.91 Acute sinusitis, unspecified J30.1 – J30.9 Allergic rhinitis, unspecified

Aspirin Desensitization:

No specific code

Oralair, Grastek and Ragwitek:

ICD-10 codes covered if selection criteria are met::

J30.1 Allergic rhinitis due to pollen

Autologous whole blood or autologous serum acupoint:

CPT codes not covered for indications listed in the CPB:

Autologous whole blood, autologous serum acupoint – no specific code

ICD-10 codes not covered for indications listed in the CPB:

L50.8 Other urticaria

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