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Coverage criteria policies

Allergy testing/Immunotherapy

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.

Administrative Process

Prior authorization is not required for allergy testing immunotherapy.

Coverage

Allergy testing is generally covered subject to the indications listed below and per your plan documents. Testing methods not generally considered standard medical procedure are not covered.

Immunotherapy (desensitization) is generally covered as long as it is consistent with generally accepted standard medical procedure.

Indications that are covered

The management of an allergic patient should include a comprehensive history, physical examination and should include confirming the cause of allergies. Once the agent is identified, treatment is provided by avoidance, medication or immunotherapy. Skin testing would be the first line of testing for the majority of patients. In vitro testing would be considered appropriate and necessary for those with the inability to stop specific medications and those that have had severe allergic responses to medicine, food, inhalants, and insects. It would be inappropriate to use in vitro testing for the majority of patients as the first line of testing.

  1. Percutaneous (scratch, puncture, pricks) or intradermal tests when IgE-mediated reactions occur to any of the following:
    1. Foods
    2. Stinging insects
    3. Inhalants
    4. Specific drugs (e.g. antibiotics or biologicals)
  2. Skin and photo patch application tests
  3. Oral ingestion challenge test
  4. In Vitro IgE Antibody tests (e.g. RAST, MAST, ELISA, ImmunoCap) when deemed medically necessary by the ordering provider

Indications that are not covered

The following tests are considered investigational. There is insufficient reliable evidence in the form of high quality peer-reviewed medical literature to establish the safety and efficacy of these tests or their effects on health care outcomes.

  1. Cytotoxicity food testing (e.g. Bryans test)
  2. Urine autoinjection (autogenous urine immunization)
  3. Provacation/Neutralization testing (e.g. Rinkel test)
  4. Provocative testing done sublingually and sublingual allergy immunotherapy for any indication (including sublingual drop immunotherapy- SLIT)

Definitions

Allergy is a hypersensitivity reaction of the immune system to something in the environment that usually causes little to no problem in most people. Reactions include allergic asthma, hay fever, food allergies, eczema, atopic dermatitis, and anaphylaxis which develop within minutes to a few hours after exposure.

In vivo refers to a medical test, experiment or procedure that is done on a living organism, such as a laboratory animal or human.

In vitro testing looks at how a drug or substance responds in the confines of a test tube or laboratory dish.

IgE Mediated reaction- Adverse reactions can be subdivided into non-toxic or toxic reactions. The term food allergy is used when an immunological mechanism has been defined or is suspected. The two broad groups of immune reactions are IgE-mediated and non-IgE-mediated. The IgE-mediated reactions are usually divided into immediate onset reactions (immediate in time) and immediate plus late-phase (in which the immediate onset symptoms are followed by prolonged or on-going symptoms). Non-IgE-mediated reactions, which are poorly defined both clinically and scientifically, are believed to be T-cell-mediated. They are typically delayed in onset, and occur 4 to 28 hours after ingestion of the offending food(s). Non-immune or non-allergic adverse reactions are termed food intolerance, for example, pharmacological reactions or intolerance to lactose.

Immunotherapy involves regular injections of offending allergens which are not readily avoidable. The treatment is provided over a period of months to years, with a goal of reducing symptoms. Allergy shots work like a vaccine. Your body responds to injected amounts of a particular allergen, given in gradually increasing doses, by developing immunity or tolerance to the allergen

Sublingual immunotherapy (SLIT) refers to allergy testing and treatment performed under the tongue (sublingual).

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. American Academy of Allergy, Asthma & Immunology, (2008). Allergy Diagnostic Testing: An Updated Practice Parameter. Annals of Asthma, Allergy & Immunology, 100(3), Supplement 3.
  2. American Academy of Allergy, Asthma & Immunology Task Force (2011) Allergen Immunotherapy: A practice parameter third update. Journal of Allergy and Clinical Immunology. 127(1); S1-S55.
  3. American Academy of Allergy, Asthma & Immunology (2016). Allergy Tests: When you need them-and when you don’t. Retrieved from http://www.choosingwisely.org
  4. U.S. Food and Drug Administration. Compliance Policy Guides- CPG Sec.370.100 Cytotoxic Testing for Allergic Diseases. Retrieved from http://www.fda.gov/iceci/compliancemanuals/compliancepolicyguidancemanual/ucm123806.htm
  5. Hayes, Inc. Hayes Medical Technology Directory Report. Allergy Testing, in Vivo. Lansdale, PA: Hayes, Inc.; August, 2009, Updated July, 2013, Archived September, 2014.
  6. Hayes, Inc. Hayes Medical Technology Directory Report. Allergy Testing for Diagnosis of Respiratory Allergy, In Vitro. Lansdale, PA: Hayes, Inc.; August, 2009. Reviewed September, 2013. Archived September, 2014.
  7. Hayes, Inc. Hayes Medical Technology Directory Report. Sublingual Immunotherapy for Allergic Rhinitis. Lansdale, PA: Hayes, Inc.; October, 2011. Reviewed March, 2015.
  8. UptoDate, Nolte, H. MD, PhD, Kowal, K, MD, DuBuske, L., MD. Overview of in vitro allergy tests. In: UpToDate, Bochner, B. (Ed), UpToDate, Waltham, MA. (Accessed on 11/15/16)

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Policy activity

  • 01/01/1994 - Date of origin
  • 11/01/2016 - Effective date
Review date
  • 11/2016

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