L31721-LCD

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Local Coverage Determination (LCD) for Allergy Testing (L31271)

Contractor Information Contractor Name First Coast Service Options, Inc.

Contractor Number

09102

Contractor Type

MAC - Part B

LCD Information

Document Information

LCD ID Number L31271

LCD Title Allergy Testing

Contractor's Determination Number 86003

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 09/30/2010 Original Determination Ending Date

Revision Effective Date

For services performed on or after 10/01/2011 Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determination (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represent quotation from one or more of the following CMS sources:

CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 20.2, 80.1 and 80.6 CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, Sections 110.9 and 110.11

CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Chapter 12, Section 200 and Chapter 16, Section 40.7

Indications and Limitations of Coverage and/or Medical Necessity

Allergy is a form of exaggerated sensitivity or hypersensitivity to a substance that is either inhaled, ingested, injected, or comes in contact with the skin or eye. The term allergy is used to describe situations where hypersensitivity results from heightened or altered reactivity of the immune system in response to external substances. Allergic or hypersensitivity disorders may be manifested by generalized systemic reactions as well as localized reactions in any part of the body. The reactions may be acute, subacute, or chronic, immediate or delayed, and may be caused by a variety of offending agents; pollen, molds, mites, dust, feathers, animal fur or dander, venoms, foods, drugs, etc.

Allergy testing is performed to determine a patient's immunologic sensitivity or reaction to particular allergens for the purpose of identifying the cause of the allergic state, and is based on findings during a complete medical and immunologic history and appropriate physical exam obtained by face-to-face contact with the patient.

Allergy testing can be broadly subdivided into two methodologies:

A. In vivo testing (skin tests): this testing correlates the performance and evaluation of selective cutaneous and mucous membrane tests with the patient’s history, physician examination, and other observations.

• Percutaneous testing (scratch, puncture, prick) and intracutaneous (intradermal) testing are used to evaluate immunoglobulin E (IgE) mediated hypersensitivity to inhalants, foods, hymenoptera (e.g., bee venom), drugs and/or chemicals.

• Patch testing to used to differentiate allergic contact dermatitis (ACD) and irritant contact dermatitis (ICD).

• Photo patch testing is used to evaluate unique allergies resulting from light exposure.

• Photo tests are performed for the evaluation of photosensitivity disorders.

B. In vitro testing (blood serum analysis): immediate hypersensitivity testing by measurement of allergen- specific serum IgE (CPT code 86003). Special clinical situations in which specific IgE immunoassays may be appropriate include the following:

• Patients with severe dermatographism, ichthyosis or generalized eczema.

• Patients who cannot be safely withdrawn from medications that interfere with skin testing (such as long- acting antihistamines, tricyclic antidepressants).

• Uncooperative patients with mental or physical impairments.

• Evaluation of cross-reactivity between insect venoms (e.g., fire ant, bee, wasp, yellow jacket, hornet).

• As adjunctive laboratory testing for disease activity of allergic bronchopulmonary aspergillosis and certain parasitic diseases.

• Patients at increased risk for anaphylactic response from skin testing based on clinical history (e.g., when an unusual allergen is not available as a licensed skin test extract), or who have a history of a previous systemic reaction to skin testing.

• Patients in whom skin testing was equivocal/inconclusive and in vitro testing is required as a confirmatory test.

Limitations

FCSO Medicare does not cover in vitro allergy testing for the following, because it is considered not medically reasonable and necessary:

• Patients with no contraindications to skin testing

• Patients being treated successfully for allergies

• Patients with mild symptoms

• Patients who have had negative skin testing for the allergy in question

In vitro testing is covered when medically reasonable and necessary as a substitute for skin testing; it is not usually necessary in addition to skin testing.

Qualitative multi-allergen screen (CPT code 86005) is a non-specific screening test that does not identify a specific antigen, and is not covered.

The use of sublingual, intracutaneous, and subcutaneous provocative and neutralization testing and neutralization therapy for food allergies are excluded from Medicare coverage because available evidence does not show that these tests and therapies are effective (CMS Manual System, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, Section 110.11).

Allergen-specific IgG and IgG subclasses measured by using immunoabsorption assays and IgG and IgG subclass antibody tests for food allergy/delayed food allergic symptoms or intolerance to specific foods (eg., CPT code 86001) are considered experimental and investigational, as there is insufficient evidence in the published peer- reviewed scientific literature to support the diagnostic value of these tests.

The following tests are considered experimental and investigational for allergy testing as they have not been proven to be effective. These tests are not appropriate for the evaluation and/or management of IgE-mediated allergic reactions.

• Antigen leukocyte cellular antibody (ALCAT) automated food allergy testing

• Applied kinesiology or Nambudripad’s allergy elimination test (NAET (i.e., muscle strength testing or measurement after allergen ingestion)

• Candidiasis test

• Chemical analysis of body tissues (e.g., hair)

• Chlorinated pesticides (serum)

• Complement (total or components)

• C-reactive protein

• Cytokine and cytokine receptor assay

• Cytotoxic testing for food, environmental or clinical ecological allergy testing (Bryans Test, ACT)

• Electrodermal testing or electro-acupuncture

• ELISA/Act qualitative antibody testing

• Food immune complex assay (FICA)

• Ingestion challenge food testing for diagnosing rheumatoid arthritis, depression, or respiratory disorders not associated with anaphylaxis or similar systemic reactions

• Immune complex assay

• Iridology

• Leukocyte histamine release test (LHRT)/basophil histamine release test

• Lymphocytes (B or T subsets)

• Lymphocyte function assay

• Lymphocyte Response Assay (LRA) by ELISA/ACT and Lymphocyte Mitogen Response Assays (LMRA) by ELISA/Act

• Mediator release test (MRT)

• Testing for multiple chemical sensitivity syndrome (a.k.a., idiopathic environmental intolerance (IEI), clinical ecological illness, clinical ecology, environmental illness, chemical AIDS, environmental/chemical hypersensitivity disease, total allergy syndrome, cerebral allergy, 20th century disease)

• Testing of specific Immunoglobulin (IgG) (e.g., by Radioallergosorbent (RAST) or Enzyme-linked immunosorbent assay (ELISA)

• Testing of total serum IgG, immunoglobulin A (IgA) and immunoglobulin M (IgM)

• Prausnitz-Kustner or P-K testing - passive cutaneous transfer test

• Pulse test (pulse response test, reaginic pulse test)

• Rebuck skin window test

• Sage Complement Antigen Test

Measurements of total IgE levels (CPT code 82785-Gammaglobulin[immunoglobulin]; IgE) are not appropriate in most general allergy testing which is performed to determine a patient’s immunologic sensitivity or reaction to particular allergens for the purpose of identifying the cause of the allergic state. It would not be expected that total serum IgE levels would be billed unless evidence exists for allergic bronchopulmonary Asperigillosis (ABPA), select immunodeficiencies, such as the syndrome of hyper-IgE, eczematous dermatitis, atopic dermatitis in children and recurrent pyogenic infections, or in the evaluation for omalizumab therapy. Serial, repeat testing of total IgE will be subject to medical review.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes

CPT Codes that SUPPORT Medical Necessity

86003 ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, EACH ALLERGEN PERCUTANEOUS TESTS (SCRATCH, PUNCTURE, PRICK) WITH ALLERGENIC EXTRACTS, IMMEDIATE TYPE 95004 REACTION, INCLUDING TEST INTERPRETATION AND REPORT BY A PHYSICIAN, SPECIFY NUMBER OF TESTS PERCUTANEOUS TESTS (SCRATCH, PUNCTURE, PRICK) SEQUENTIAL AND INCREMENTAL, WITH DRUGS, 95010 BIOLOGICALS OR VENOMS, IMMEDIATE TYPE REACTION, INCLUDING TEST INTERPRETATION AND REPORT BY A PHYSICIAN, SPECIFY NUMBER OF TESTS INTRACUTANEOUS (INTRADERMAL) TESTS, SEQUENTIAL AND INCREMENTAL, WITH DRUGS,

95015 BIOLOGICALS, OR VENOMS, IMMEDIATE TYPE REACTION, INCLUDING TEST INTERPRETATION AND REPORT BY A PHYSICIAN, SPECIFY NUMBER OF TESTS

95024 INTRACUTANEOUS (INTRADERMAL) TESTS WITH ALLERGENIC EXTRACTS, IMMEDIATE TYPE REACTION, INCLUDING TEST INTERPRETATION AND REPORT BY A PHYSICIAN, SPECIFY NUMBER OF TESTS INTRACUTANEOUS (INTRADERMAL) TESTS, SEQUENTIAL AND INCREMENTAL, WITH ALLERGENIC

95027 EXTRACTS FOR AIRBORNE ALLERGENS, IMMEDIATE TYPE REACTION, INCLUDING TEST INTERPRETATION AND REPORT BY A PHYSICIAN, SPECIFY NUMBER OF TESTS

95028 INTRACUTANEOUS (INTRADERMAL) TESTS WITH ALLERGENIC EXTRACTS, DELAYED TYPE REACTION, INCLUDING READING, SPECIFY NUMBER OF TESTS

95044 PATCH OR APPLICATION TEST(S) (SPECIFY NUMBER OF TESTS)

95052 PHOTO PATCH TEST(S) (SPECIFY NUMBER OF TESTS)

95056 PHOTO TESTS

95060 OPHTHALMIC MUCOUS MEMBRANE TESTS

CPT Codes that DO NOT Support Medical Necessity

*86343 Leukocyte histamine release test (LHR)

*86628 Candida

*95831 Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk

*95832 hand, with or without comparison with normal side

*95833 total evaluation of body, excluding hands

*95834 total evaluation of body, including hands

*Services which are also listed in the FCSO LCD for Noncovered Services

83516 IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN; QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP METHOD

84600 VOLATILES (EG, ACETIC ANHYDRIDE, CARBON TETRACHLORIDE, DICHLOROETHANE, DICHLOROMETHANE, DIETHYLETHER, ISOPROPYL ALCOHOL, METHANOL)

86001 ALLERGEN SPECIFIC IGG QUANTITATIVE OR SEMIQUANTITATIVE, EACH ALLERGEN

86005 ALLERGEN SPECIFIC IGE; QUALITATIVE, MULTIALLERGEN SCREEN (DIPSTICK, PADDLE, OR DISK)

86140 C-REACTIVE PROTEIN

86160 COMPLEMENT; ANTIGEN, EACH COMPONENT

86161 COMPLEMENT; FUNCTIONAL ACTIVITY, EACH COMPONENT

86162 COMPLEMENT; TOTAL HEMOLYTIC (CH50)

86332 IMMUNE COMPLEX ASSAY

86485 SKIN TEST; CANDIDA

88342 IMMUNOHISTOCHEMISTRY (INCLUDING TISSUE IMMUNOPEROXIDASE), EACH ANTIBODY

88346 IMMUNOFLUORESCENT STUDY, EACH ANTIBODY; DIRECT METHOD

95065 DIRECT NASAL MUCOUS MEMBRANE TEST

ICD-9 Codes that Support Medical Necessity

The following ICD-9-CM codes apply only to CPT code 86003:

372.05 ACUTE ATOPIC CONJUNCTIVITIS

372.14 OTHER CHRONIC ALLERGIC CONJUNCTIVITIS

477.1 ALLERGIC RHINITIS DUE TO POLLEN

477.2 ALLERGIC RHINITIS DUE TO FOOD

477.3 ALLERGIC RHINITIS, DUE TO ANIMAL (CAT) (DOG) HAIR AND DANDER

477.8 ALLERGIC RHINITIS DUE TO OTHER ALLERGEN

477.9 ALLERGIC RHINITIS CAUSE UNSPECIFIED

493.1 EXTRINSIC ASTHMA UNSPECIFIED

493.2 EXTRINSIC ASTHMA WITH STATUS ASTHMATICUS

493.3 EXTRINSIC ASTHMA WITH (ACUTE) EXACERBATION

493.90 ASTHMA UNSPECIFIED

493.91 ASTHMA UNSPECIFIED TYPE WITH STATUS ASTHMATICUS

493.92 ASTHMA UNSPECIFIED WITH (ACUTE) EXACERBATION

691.8 OTHER ATOPIC DERMATITIS AND RELATED CONDITIONS

692.9 CONTACT DERMATITIS AND OTHER ECZEMA UNSPECIFIED CAUSE

693.1 DERMATITIS DUE TO DRUGS AND MEDICINES TAKEN INTERNALLY

693.2 DERMATITIS DUE TO FOOD TAKEN INTERNALLY

693.8 DERMATITIS DUE TO OTHER SPECIFIED SUBSTANCES TAKEN INTERNALLY

693.9 DERMATITIS DUE TO UNSPECIFIED SUBSTANCE TAKEN INTERNALLY

708.0 ALLERGIC URTICARIA

708.3 DERMATOGRAPHIC URTICARIA

708.8 OTHER SPECIFIED URTICARIA

708.9 UNSPECIFIED URTICARIA

782.1 RASH AND OTHER NONSPECIFIC SKIN ERUPTION

989.5 TOXIC EFFECT OF VENOM

989.82 TOXIC EFFECT OF LATEX

995.1 OTHER ANAPHYLACTIC REACTION

995.2 ANGIONEUROTIC EDEMA NOT ELSEWHERE CLASSIFIED

995.20 UNSPECIFIED ADVERSE EFFECT OF UNSPECIFIED DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE

995.22 UNSPECIFIED ADVERSE EFFECT OF ANESTHESIA

995.27 OTHER DRUG ALLERGY

995.29 UNSPECIFIED ADVERSE EFFECT OF OTHER DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE

995.3 ALLERGY UNSPECIFIED NOT ELSEWHERE CLASSIFIED

995.60 ANAPHYLACTIC REACTION DUE TO UNSPECIFIED FOOD

995.61 ANAPHYLACTIC REACTION DUE TO PEANUTS

995.62 ANAPHYLACTIC REACTION DUE TO CRUSTACEANS

995.63 ANAPHYLACTIC REACTION DUE TO FRUITS AND VEGETABLES

995.64 ANAPHYLACTIC REACTION DUE TO TREE NUTS AND SEEDS

995.65 ANAPHYLACTIC REACTION DUE TO FISH

995.66 ANAPHYLACTIC REACTION DUE TO FOOD ADDITIVES

995.67 ANAPHYLACTIC REACTION DUE TO MILK PRODUCTS

995.68 ANAPHYLACTIC REACTION DUE TO EGGS

995.69 ANAPHYLACTIC REACTION DUE TO OTHER SPECIFIED FOOD

V15.09* PERSONAL HISTORY OF OTHER ALLERGY OTHER THAN TO MEDICINAL AGENTS

* ICD-9-CM code V15.09 should be used as a secondary code only and should not be billed as the primary diagnosis.

The following ICD-9-CM codes apply only to CPT codes *95004, 95010, 95015, 95024, 95027, and 95028:

372.05 ACUTE ATOPIC CONJUNCTIVITIS

372.14 OTHER CHRONIC ALLERGIC CONJUNCTIVITIS

472.0 CHRONIC RHINITIS

477.1 ALLERGIC RHINITIS DUE TO POLLEN

477.2 ALLERGIC RHINITIS DUE TO FOOD

477.3 ALLERGIC RHINITIS, DUE TO ANIMAL (CAT) (DOG) HAIR AND DANDER

477.8 ALLERGIC RHINITIS DUE TO OTHER ALLERGEN

477.9 ALLERGIC RHINITIS CAUSE UNSPECIFIED

493.1 EXTRINSIC ASTHMA UNSPECIFIED

493.2 EXTRINSIC ASTHMA WITH STATUS ASTHMATICUS

493.3 EXTRINSIC ASTHMA WITH (ACUTE) EXACERBATION

691.8 OTHER ATOPIC DERMATITIS AND RELATED CONDITIONS 693.1* DERMATITIS DUE TO FOOD TAKEN INTERNALLY

698.9 UNSPECIFIED PRURITIC DISORDER

708.0 ALLERGIC URTICARIA

708.8 OTHER SPECIFIED URTICARIA

989.5 TOXIC EFFECT OF VENOM

989.82 TOXIC EFFECT OF LATEX

995.1 OTHER ANAPHYLACTIC REACTION

995.2 ANGIONEUROTIC EDEMA NOT ELSEWHERE CLASSIFIED

995.20 UNSPECIFIED ADVERSE EFFECT OF UNSPECIFIED DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE

995.27 OTHER DRUG ALLERGY

995.29 UNSPECIFIED ADVERSE EFFECT OF OTHER DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE

995.3 ALLERGY UNSPECIFIED NOT ELSEWHERE CLASSIFIED

995.4 SHOCK DUE TO ANESTHESIA NOT ELSEWHERE CLASSIFIED 995.60* ANAPHYLACTIC REACTION DUE TO UNSPECIFIED FOOD 995.61* ANAPHYLACTIC REACTION DUE TO PEANUTS

995.62 * ANAPHYLACTIC REACTION DUE TO CRUSTACEANS

995.63 * ANAPHYLACTIC REACTION DUE TO FRUITS AND VEGETABLES

995.64 * ANAPHYLACTIC REACTION DUE TO TREE NUTS AND SEEDS

995.65 * ANAPHYLACTIC REACTION DUE TO FISH

995.66 * ANAPHYLACTIC REACTION DUE TO FOOD ADDITIVES

995.67 * ANAPHYLACTIC REACTION DUE TO MILK PRODUCTS

995.68 * ANAPHYLACTIC REACTION DUE TO EGGS

995.69 * ANAPHYLACTIC REACTION DUE TO OTHER SPECIFIED FOOD

995.7* OTHER ADVERSE FOOD REACTIONS NOT ELSEWHERE CLASSIFIED V14.0* PERSONAL HISTORY OF ALLERGY TO PENICILLIN

V14.1* PERSONAL HISTORY OF ALLERGY TO OTHER ANTIBIOTIC AGENT V14.2* PERSONAL HISTORY OF ALLERGY TO SULFONAMIDES

V14.3* PERSONAL HISTORY OF ALLERGY TO OTHER ANTI-INFECTIVE AGENT V14.7* PERSONAL HISTORY OF ALLERGY TO SERUM OR VACCINE

V14.8* PERSONAL HISTORY OF ALLERGY TO OTHER SPECIFIED MEDICINAL AGENTS V15.01* PERSONAL HISTORY OF ALLERGY TO PEANUTS

V15.02* PERSONAL HISTORY OF ALLERGY TO MILK PRODUCTS V15.03* PERSONAL HISTORY OF ALLERGY TO EGGS

V15.04* PERSONAL HISTORY OF ALLERGY TO SEAFOOD V15.05* PERSONAL HISTORY OF ALLERGY TO OTHER FOODS V15.06* ALLERGY TO INSECTS AND ARACHNIDS

*ICD-9-CM codes that apply for CPT code 95004 for food allergy testing.

**ICD-9-CM ‘V’ codes should be used as a secondary code only and should not be billed as the primary diagnosis.

The following ICD-9-CM codes apply only to CPT codes 95044, 95052 and 95056:

691.8 OTHER ATOPIC DERMATITIS AND RELATED CONDITIONS

692.1 CONTACT DERMATITIS AND OTHER ECZEMA DUE TO DETERGENTS

692.2 CONTACT DERMATITIS AND OTHER ECZEMA DUE TO OILS AND GREASES

692.3 CONTACT DERMATITIS AND OTHER ECZEMA DUE TO SOLVENTS

692.4 CONTACT DERMATITIS AND OTHER ECZEMA DUE TO DRUGS AND MEDICINES IN CONTACT WITH SKIN

692.5 CONTACT DERMATITIS AND OTHER ECZEMA DUE TO OTHER CHEMICAL PRODUCTS

692.6 CONTACT DERMATITIS AND OTHER ECZEMA DUE TO FOOD IN CONTACT WITH SKIN

692.7 CONTACT DERMATITIS AND OTHER ECZEMA DUE TO PLANTS (EXCEPT FOOD)

692.81 DERMATITIS DUE TO COSMETICS

692.83 DERMATITIS DUE TO METALS

692.89 CONTACT DERMATITIS AND OTHER ECZEMA DUE TO OTHER SPECIFIED AGENTS

692.9 CONTACT DERMATITIS AND OTHER ECZEMA UNSPECIFIED CAUSE

The following ICD-9-CM codes apply only to CPT code 95060:

372.05 ACUTE ATOPIC CONJUNCTIVITIS

372.14 OTHER CHRONIC ALLERGIC CONJUNCTIVITIS

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity

The following ICD-9-CM codes are noncovered for procedure codes 86005, 86160, 86161, 86162:

692.5 CONTACT DERMATITIS AND OTHER ECZEMA DUE TO FOOD IN CONTACT WITH SKIN

693.1 DERMATITIS DUE TO FOOD TAKEN INTERNALLY

995.60 - 995.69 ANAPHYLACTIC REACTION DUE TO UNSPECIFIED FOOD - ANAPHYLACTIC REACTION DUE TO OTHER SPECIFIED FOOD

995.7 OTHER ADVERSE FOOD REACTIONS NOT ELSEWHERE CLASSIFIED

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Medical record documentation (e.g., history & physical, office/progress notes, procedure report, test results) must include the following information, and be available to FCSO Medicare upon request:

• A complete medical and immunologic history and appropriate physical exam obtained by face-to-face contact with the patient.

• The medical necessity for performing the test.

• The test methodology used.

• The measurement (in mm) of reaction sizes of both wheal and erythema response (in vivo testing).

• The medical necessity for the use of in vitro testing if used, instead of in vivo methods.

• The quantitative result (in kIU/L) for specific IgE testing (in vitro testing).

• The interpretation of the test results and how the results of the test will be used in the patient’s plan of care.

Per 42 CFR §410.32, all diagnostic tests must be ordered by the physician/nonphysician practitioner who is treating the patient, that is, the physician/nonphysician practitioner who furnishes a consultation or treats a patient for a specific medical problem and who uses the results in the management of the patient’s specific medical problem. Tests not ordered by the physician/nonphysician practitioner who is treating the patient are not reasonable and necessary.

Providers should not submit additional information with the claim. FCSO Medicare may request it separately with an additional documentation request (ADR) letter.

Appendices

Utilization Guidelines

It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

It would not be expected that all patients would receive the same tests or the same number of sensitivity tests. The number of tests performed must be judicious and related to the history, physical findings and clinical judgment specific to each individual patient.

In vitro testing is covered when medically reasonable and necessary as a substitute for skin testing; it is not usually necessary in addition to skin testing.

In vitro testing (CPT code 86003) will be covered for only thirty (30) units per year for medically reasonable and necessary indications as outlined in this LCD. Services exceeding this parameter will be considered not medically necessary.

It would not be expected that more than twenty (20) units be reported for percutaneous testing per year for food sensitivity (CPT code 95004).

It would not be expected that more than forty (40) units be reported for intracutaneous (intradermal) testing (CPT code 95024) per year for a patient.

It would not be expected that more than forty (40) units be reported for intracutaneous (intradermal), sequential and incremental testing (CPT code 95027) per year for a patient.

When photo patch test(s) (CPT code 95052) are performed (same antigen/same session) with patch or application test(s) (CPT code 95044), only the photo patch tests should be reported.

In the event photo tests (CPT code 95056) are performed with patch or application test(s) (CPT code 95044), only the photo tests should be reported.

Sources of Information and Basis for Decision

Contact dermatitis: a practice parameter. (2006). The American Academy of Allergy, Asthma and Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI), 100, S1-S38.

Food allergy: a practice parameter. (2006). The American Academy of Allergy, Asthma and Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI), 96, S1-S68.

Other Contractor(s) LCDs

Practice parameters for allergy diagnostic testing: An updated practice parameter. (2008). The American Academy of Allergy, Asthma and Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI), 100(3), S1-S148. Retrieved on August 31, 2009 from http://www.acaai.org/Member/PracticeParam/default.htm.

Wang, J., Godbold, J., & Sampson, H. (2008). Correlation of serum allergy (IgE) tests performed by different assay systems. J Allergy Clin Immunol, 121, 1219-1224.

Wood, R., Segall, N., Ahlstedt, S., & Williams, P. (2007). Accuracy of IgE antibody laboratory results. Ann Allergy, Asthma & Immunol, 99, 34-41.

U.S. Department of Health and Human Services. (2008) National asthma education and prevention program guidelines implementation panel report 3-Guidelines for the diagnosis and management of asthma, (NIH Publication No. 09-6147), 1-44 (Retrieved on November 10, 2009 from http://www.nhlbi.nih.gov/guidelines/asthma/gip_rpt.htm on November 10.

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was developed in cooperation with advisory groups, which includes representatives from numerous societies.

Florida Contractor Advisory Committee meeting, June 12, 2010.

Puerto Rico and U.S. Virgin Islands Contractor Advisory Committee meeting, June 17, 2010.

Start Date of Comment Period 05/28/2010

End Date of Comment Period 07/11/2010

Start Date of Notice Period 08/16/2010

Revision History Number 1

Revision History Explanation Revision Number:1 Start Date of Comment Period:N/A

Start Date of Notice Period:10/01/2011 Revised Effective Date: 10/01/2011

LCR B2011-101

September 2011 Connection

Explanation of Revision: Annual 2012 ICD-9-CM Update. Revised descriptor for diagnosis code range 995.60-

995.69 for CPT codes 86003, 86005, 86160, 86161, 86162, and 95004. Revised descriptor for diagnosis code

995.0 for CPT codes 86003, 95004, 95010, 95015, 95024, 95027, and 95028. The effective date of this revision is based on date of service.

Revision Number Original

Start Date of Comment Period:05/28/2010 Start Date of Notice Period:08/16/2010 Original Effective Date 09/30/2010

LCR B2010-065

August 2010 Update

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

95024 descriptor was changed in Group 1 83516 descriptor was changed in Group 2 86160 descriptor was changed in Group 2 86162 descriptor was changed in Group 2 86485 descriptor was changed in Group 2

08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.

11/21/2011 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

86140 descriptor was changed in Group 2

Reason for Change