L56.0 — Drug phototoxic response
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Supportive documentation evidencing the condition and treatment must be documented in the medical record and be available to the Contractor upon request.
- ICD-10-CM diagnosis codes supporting the medical necessity of the service must be submitted with each claim.
- High-utilization or repeat testing should include clinical justification in the record (for example, repeat testing due to unsatisfactory response to treatment) to support medical necessity.
- A complete medical and immunologic history and appropriate physical examination must be documented prior to diagnostic testing.
Key Coverage Criteria
- Allergy testing for inhalant allergens is covered when medically necessary; evaluation may include up to 90 prick-puncture tests followed by up to 40 intracutaneous tests if prick/puncture results are negative.
- Allergy testing for food sensitivity is covered when medically necessary and may require up to 40 percutaneous tests.
- Multitest intracutaneous testing of up to 60 tests may be appropriate in lieu of prick-puncture testing for selected patients (for example, young children, older adults, or needle-phobic individuals).
- Exceeding the stated testing parameters may be covered when preliminary testing failed and immunotherapy failed to control symptoms, provided documentation supports medical necessity.
- Photo testing and photopatch testing are covered for the evaluation of photosensitivity disorders and allergies related to light exposure.
- Allergy testing for immediate (IgE-mediated) and delayed (cell-mediated) hypersensitivity is covered when supported by scientifically valid peer-reviewed medical studies.
2 Active Policies
A57181 — Billing and Coding: Allergy Testing
L34313 — Allergy Testing
Related Codes
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