95071
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clinical documentation of clinically significant allergic symptoms and that testing is part of a complete diagnostic evaluation.
- Documentation from the licensed practitioner confirming scope-of-practice and justification for selected antigens (i.e., likelihood of member exposure).
- Record of number/units of tests performed to demonstrate compliance with state-specific unit limits or applicable NCCI MUE limits.
- Documentation of negative percutaneous (skin prick) test results when performing intracutaneous (intradermal) testing.
Key Coverage Criteria
- Allergy testing to determine immunologic sensitivity for immediate (IgE-mediated) hypersensitivity.
- Allergy testing to determine immunologic sensitivity for delayed (cell-mediated) hypersensitivity.
- Allergen immunotherapy (repeated administration of specific allergens) for patients with IgE-mediated allergic conditions to reduce allergic symptoms and inflammatory reactions.
- Allergy testing is medically necessary for members with clinically significant allergic symptoms as part of a complete diagnostic evaluation by a licensed practitioner acting within their scope.
- Testing should include only antigens that the member is reasonably likely to be exposed to.
- Percutaneous testing (scratch, puncture, prick) is indicated to evaluate suspected offending allergens such as pollen, molds, mites, dust, feathers, animal fur/dander, venoms, foods, or drugs (CPT 95004, 95017, 95018).
1 Active Policy
AMBETTER-CP.MP.100 — Allergy Testing
Related Codes
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