Highmark Commercial Medical Policy - Pennsylvania


 
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Medical Policy: L-3-022
Topic: In Vitro Allergy Testing
Section: Laboratory
Effective Date: January 1, 2018
Issue Date: May 14, 2018
Last Reviewed: August 2017

In vitro allergy testing determines whether a patient's serum contains immunoglobulin E (IgE) antibodies against specific allergens of clinical importance. The radioallergosorbent (RAST) test was developed for in vitro (blood) measurement of specific IgE in a patient’s serum. There are several other tests that employ the same principle using different detection systems.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

In vitro allergy testing for IgE may be considered medically necessary when ANY of the following are met:

  • Direct skin testing is impossible due to an extensive dermatitis or marked dermatographism; or
  • Direct skin testing is contraindicated because of concomitant drug treatment (e.g., psychotropic drugs frequently have H1 blocking characteristics); or
  • When there is difficulty in testing uncooperative patients (e.g., small children or patients with mental or physical impairments); or
  • If direct skin testing has been inconclusive; or
  • As adjunctive tests for allergic bronchopulmonary aspergillosis or parasitic disease; or
  • Individuals who have a clinical history suggesting an unusually greater risk for anaphylaxis or who have had a previous systemic reaction to skin testing; or
  • For evaluation of cross-reactivity between insect venoms.

In vitro allergy testing for IgE exceeding 36 tests per year is considered not medically necessary.

In vitro allergy testing for IgE that does not meet the criteria of this policy is considered not medically necessary.

Procedure Codes
86003, 86008



Elisa/Act qualitative antibody testing and IgG ELISA, indirect method are considered experimental/investigational and, therefore, non-covered. Scientific evidence does not demonstrate the usefulness of these tests in allergy testing and treatment.

Procedure Codes
86001



ALCAT (Antigen Leukocyte Cellular Antibody Test) allergy testing is considered experimental/investigational and, therefore, non-covered.  Scientific evidence does not demonstrate the usefulness of these tests.

Procedure Codes
83516



Refer to medical policy Z-26, Allergy Skin Testing, for additional information.


Place of Service: Outpatient

In vitro allergy testing is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business


Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Quantity level limits or quantity of supplies that exceed the frequency guidelines listed on the policy will be denied as not medically necessary.


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Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages
If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.



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