| Highmark Commercial Medical Policy - Pennsylvania |
| Medical Policy: | Z-26-020 |
| Topic: | Allergy Skin Testing |
| Section: | Miscellaneous |
| Effective Date: | June 13, 2016 |
| Issue Date: | June 13, 2016 |
| Last Reviewed: | March 2016 |
An allergy is an abnormal reaction to an ordinarily harmless substance called an allergen. When an allergen (such as pollen) is absorbed into the body of an allergic individual that individual's immune system views the allergen as an invader and a chain reaction is initiated. White blood cells of the immune system produce IgE antibodies. These antibodies attach themselves to special mast cells causing a release of potent chemicals such as histamine. Allergic or hypersensitivity disorders may be manifested by generalized systemic reactions in any organ system of the body. The reactions may be acute, sub-acute or chronic, immediate or delayed, and may be caused by an endless variety of fur, venoms, foods, drugs, etc. The ideal management of the allergic patient is to identify the offending agent by various means of testing. |
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. |
Allergy testing may be considered medically necessary in the diagnosis of allergies by ANY ONE of the following techniques:
A Cumulative total of 70 percutaneous or 40 intracutaneous tests per benefit year. Payment should not be made in excess of this limit except in extraordinary circumstances.
Skin Endpoint Titration (SET) used in conjunction with immuno-therapy may be considered medically necessary with ANY ONE of the following criteria when there is potential for the specific allergen in question to produce a severe systemic allergic reaction or anaphylaxis:
A cumulative total of 80 tests for SET testing per benefit year. Payment should not be made in excess of this limit except in extraordinary circumstances.
Allergy testing methods with ANY ONE of the following are considered not medically necessary.
| Place of Service: Outpatient |
Allergy Skin 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 |
| FEP Guidelines |
This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits or a contract. Benefits are determined by the Federal Employee Program. |
| 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.
Quantity level limits or quantity of supplies that exceed the frequency guidelines listed on the policy will be denied as non-covered. A network provider cannot bill the member for the non-covered service.
| Links |
05/2015, Allergy Skin Testing Criteria Revised
06/2015, Correction 05/2015 MPU: Allergy Skin Testing Criteria Revised
