Procedure code and description



95004 Percut Tests w/ Extrac Immed React # Allergy testing – Percut allergy skin tests –  Percutaneous tests (prick or puncture), specify number of tests (1 prick = 1 test) – Average fee amount $6 – $8


86003 Allergen specific ige – 



95024 Intracutaneous (intradermal) tests, specify number of tests. Use this code when doing no more than one intradermal test per antigen. (e.g. MQT)




95027 Intracutaneous (intradermal) tests, sequential and incremental, specify number of tests. Use this code when doing more than one ID test per antigen. (e.g. IDT) 95024 and 95027 may be billed at the same time.

Coverage Indications, Limitations, and/or Medical Necessity


Allergy skin testing is a clinical procedure that is used to evaluate an immunologic response to allergenic material. The need for testing and interpretation of test findings must be correlated with signs and symptoms of possible allergies as determined by a complete history and physical examination of the patient. The number and type of antigens used for testing must be chosen judiciously given the patient’s presentation and the tester’s clinical judgment.

Allergy testing is covered when clinically significant allergic history or symptoms that are not controllable by empiric conservative therapy exists. For Medicare to cover allergy testing, the following criteria must be met:
  • Testing must correlate specifically to the patient’s history and physical findings.
  • The test technique and/or allergens tested must have proven efficacy demonstrated through scientifically valid medical studies published in peer-reviewed literature.
  • Allergy testing must be performed on patients whose environment provides the reasonable probability of exposure to the specific antigen tested.


Percutaneous, Intradermal, Intracutaneous Testing
Percutaneous testing is the usual preferred method for allergy testing. Medicare covers percutaneous (scratch, prick or puncture) testing when IgE-mediated reactions occur to any of the following:

  • Inhalants.
  • Foods.
  • Hymenoptera (stinging insects).
  • Specific drugs (penicillins and macromolecular agents).
In selected patients, intradermal testing for the same antigen may be necessary to test persons whose percutaneous test was negative. For intradermal testing, the clinician should narrow the area of investigation so that the minimal number of skin tests necessary for diagnosis is performed. Medicare covers intradermal (intracutaneous) testing when IgE-mediated reactions occur to any of the following:
  • Inhalants.
  • Hymenoptera (stinging insects).
  • Specific drugs (penicillins and macromolecular agents).
Retesting with the same antigen(s) should rarely be necessary within a three-year period. Exceptions include young children with negative skin tests or older children and adults with negative skin tests in the face of persistent symptoms. Routine repetition of skin tests is not indicated (i.e., annually).
Percutaneous testing for food allergens is covered for patients with a clinical presentation suggestive of significant food allergy. Such patients will have presented with signs and symptoms of such conditions as angioedema, urticaria or anaphylaxis after ingestion of specific foods. Testing for food allergies in patients who present with wheezing is occasionally required.


Patch Testing
Patch testing is the standard method of identifying the cause of allergic contact dermatitis, a delayed cell-mediated type IV hypersensitivity reaction. The standard series of 24 patch tests or a specific allergen is applied to the skin on the patient’s back and left in place for 48 hours. The test is read after 48 hours and sometimes again after 96 hours and reactions are graded from no response (grade 0) to a blistering reaction (grade 4).

A positive patch test provides a very specific etiology of a patient’s allergic contact dermatitis. Avoidance of the identified allergen(s) is the treatment of choice.

This is a covered procedure only when used to diagnose allergic contact dermatitis after the following exposures:


  • Due to detergents (692.0).
  • Due to oils and greases (692.1).
  • Due to solvents (692.2).
  • Due to drugs and medicines in contact with skin (692.3).
  • Due to other chemical products (692.4).
  • Due to food in contact with skin (692.5).
  • Due to plants [except food] (692.6).
  • Dermatitis due to cosmetics (692.81).
  • Dermatitis due to metals (692.83).
  • Dermatitis due to other (692.89). ICD-9-CM code 692.89 is used for dermatitis due to: cold weather, furs, hot weather and preservatives).
  • Dermatitis due to latex allergy. Use ICD-9-CM code 692.89 for this indication.
  • Dermatitis due to unspecified cause (692.9) is to be utilized for those patients with suspected allergic contact dermatitis but in whom the etiology is not apparent. Prior unresponsive treatments (topical medications, etc.) should be documented in the patient’s chart before initiating patch tests.
  •  


Limitations
The following allergy testing is non-covered by Medicare:

  • Provocative and neutralization testing and neutralization therapy of food allergies (sublingual, intracutaneous and subcutaneous) are excluded from Medicare coverage because available evidence does not show these tests and therapies are effective.
  • Qualitative multi-allergen screens have insufficient literature demonstrating clear-cut clinical utility and are therefore, non-covered.
  • Late reactions occurring with allergenic extracts are of unclear clinical significance and are therefore, non-covered.
  • Intradermal testing for food allergens.
  • Food allergen testing for patients who present with respiratory symptoms other than wheezing and asthma.
  • Food allergen testing for patients who present with gastrointestinal symptoms suggestive of food intolerance.
  • Skin endpoint testing.
  • Allergy testing for antigens for which no clinical efficacy is documented in peer-reviewed literature. Such antigens include but are not limited to the following:
    • Grain mill dust (pollen grains of cereals/related crops are large; they do not become airborne).
    • Tobacco smoke (no component has ever been shown to be a respiratory allergen).
    • Orris root (almost never used in cosmetics these days; test adds nothing to evaluation).
    • Dandelion (non-allergenic; no pollen produced).
    • Marigold (non-allergenic; no airborne pollen produced).
    • Honeysuckle (non-allergenic; non-significant airborne pollen produced).



Note: See related article for coding guidelines.
Allergy testing for certain antigens is covered only when performed on patients whose environment provides the reasonable probability of their exposure to antigens tested. Such antigens include but are not limited to the following:
  • Tobacco leaf for tobacco workers.
  • Pyrethrum for florists (non-allergenic; found in some insecticides; cross-reacts strongly with ragweed).
  • Goldenrod for florists (pollen not carried by wind).
  • Soybean dust for workers in food processing plants.
  • Wool for patients exposed to sheep or unprocessed wool (processed wool is non-allergenic).
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.



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.
12X, 13X, 18X, 21X, 23X, 71X, 72X, 83X, 85X

CPT/HCPCS Codes
Note:
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT books. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.

86003 Allergen specific ige
95004©
Percut allergy skin tests
95010©
Sensitivity skin tests
95015©
Sensitivity skin tests
95024©
Id allergy test, drug/bug
95044©
Allergy patch tests
A. The following allergy tests are covered benefits:


1. IgE Specific Antibody (e.g., RAST, micro-Elisa, immunocap) if clinically indicated for history of severe urticaria, hives, or severe allergy, when skin testing is inappropriate.


2. Skin tests (scratch, intradermal, pricks)


3. Patch application tests


4. Drug Provocation testing



5. Skin Endpoint Titration (SET). Skin endpoint titration is effective for quantifying patient sensitivity and for providing a safe starting dose for immunotherapy. SET has not been shown to be an effective guide to a final therapeutic dose.




Coding Guidelines: Allergy Testing and Immunotherapy.


If percutaneous or intracutaneous (intradermal) single test (CPT codes 95004 or 95024) and “sequential and incremental” tests (CPT codes, 95017, 95018, or 95027) are performed on the same date of service, both the “sequential and incremental” test and single test codes may be reported if the tests are for different allergens or different dilutions of the same allergen. The unit of service to report is the number of separate tests. A single test and a “sequential and incremental” test for the same dilution of an allergen should not be reported separately on the same date of service. For example, if the single test for an antigen is positive and the physician proceeds to “sequential and incremental” tests with three additional different dilutions of the same antigen, the physician may report one unit of service for the single test code and three units of service for the “sequential and incremental” test code.


Photo patch tests (CPT code 95052) consist of applying a patch(s) containing allergenic substance(s) (same antigen/same session) to the skin and exposing the skin to light. Physicians should not unbundle this service by reporting both CPT code 95044 (patch or application tests) plus CPT code 95056 (photo tests) rather than CPT code 95052.



Evaluation and management (E/M) codes reported with allergy testing or allergy immunotherapy are appropriate only if a significant, separately identifiable service is performed. If E/M services are reported, modifier 25 should be utilized.




95004–95079 Allergy testing Bill with a count representing the number of tests performed; 95004, 95024 and 95044 reimbursed for professional services only 95004, 95024, 95027


Percutaneous tests with allergenic extracts, Intracutaneous tests with allergenic extracts immediate type reaction and intracutaneous tests sequential and incremental with allergenic extracts These codes include the test interpretation and
report 



ICD-10 Codes that Support Medical Necessity


    The following ICD-10-CM codes apply only to CPT code 86003:
  
    H10.10 Acute atopic conjunctivitis, unspecified eye
    H10.11 Acute atopic conjunctivitis, right eye
    H10.12 Acute atopic conjunctivitis, left eye
    H10.13 Acute atopic conjunctivitis, bilateral
    H10.411 Chronic giant papillary conjunctivitis, right eye
    H10.412 Chronic giant papillary conjunctivitis, left eye
    H10.413 Chronic giant papillary conjunctivitis, bilateral
    H10.419 Chronic giant papillary conjunctivitis, unspecified eye
    H10.45 Other chronic allergic conjunctivitis
    J30.0 Vasomotor rhinitis
    J30.1 Allergic rhinitis due to pollen
    J30.2 Other seasonal allergic rhinitis
    J30.5 Allergic rhinitis due to food
    J30.81 Allergic rhinitis due to animal (cat) (dog) hair and dander
    J30.89 Other allergic rhinitis
    J30.9 Allergic rhinitis, unspecified
    J45.20 Mild intermittent asthma, uncomplicated
    J45.21 Mild intermittent asthma with (acute) exacerbation
    J45.22 Mild intermittent asthma with status asthmaticus
    J45.30 Mild persistent asthma, uncomplicated
    J45.31 Mild persistent asthma with (acute) exacerbation
    J45.32 Mild persistent asthma with status asthmaticus
    J45.40 Moderate persistent asthma, uncomplicated
    J45.41 Moderate persistent asthma with (acute) exacerbation
    J45.42 Moderate persistent asthma with status asthmaticus
    J45.50 Severe persistent asthma, uncomplicated
    J45.51 Severe persistent asthma with (acute) exacerbation
    J45.52 Severe persistent asthma with status asthmaticus
    J45.901 Unspecified asthma with (acute) exacerbation
    J45.902 Unspecified asthma with status asthmaticus
    J45.909 Unspecified asthma, uncomplicated
    J45.998 Other asthma
    L20.0 Besnier’s prurigo
    L20.81 Atopic neurodermatitis
    L20.82 Flexural eczema
    L20.84 Intrinsic (allergic) eczema
    L20.89 Other atopic dermatitis
    L20.9 Atopic dermatitis, unspecified
    L23.9 Allergic contact dermatitis, unspecified cause
    L24.9 Irritant contact dermatitis, unspecified cause
    L25.9 Unspecified contact dermatitis, unspecified cause
    L27.0 Generalized skin eruption due to drugs and medicaments taken internally
    L27.1 Localized skin eruption due to drugs and medicaments taken internally
    L27.2 Dermatitis due to ingested food
    L27.8 Dermatitis due to other substances taken internally
    L27.9 Dermatitis due to unspecified substance taken internally
    L30.0 Nummular dermatitis
    L30.2 Cutaneous autosensitization
    L30.8 Other specified dermatitis
    L30.9 Dermatitis, unspecified
    L50.0 Allergic urticaria
    L50.3 Dermatographic urticaria
    L50.9 Urticaria, unspecified
    R21 Rash and other nonspecific skin eruption
    T36.0X5A Adverse effect of penicillins, initial encounter
    T36.0X5D Adverse effect of penicillins, subsequent encounter
    T36.0X5S Adverse effect of penicillins, sequela
    T36.1X5A Adverse effect of cephalosporins and other beta-lactam antibiotics, initial encounter
    T36.1X5D Adverse effect of cephalosporins and other beta-lactam antibiotics, subsequent encounter
    T36.1X5S Adverse effect of cephalosporins and other beta-lactam antibiotics, sequela
    T36.2X5A Adverse effect of chloramphenicol group, initial encounter
    T36.2X5D Adverse effect of chloramphenicol group, subsequent encounter
    T36.2X5S Adverse effect of chloramphenicol group, sequela
    T36.3X5A Adverse effect of macrolides, initial encounter
    T36.3X5D Adverse effect of macrolides, subsequent encounter
    T36.3X5S Adverse effect of macrolides, sequela
    T36.4X5A Adverse effect of tetracyclines, initial encounter
    T36.4X5D Adverse effect of tetracyclines, subsequent encounter
    T36.4X5S Adverse effect of tetracyclines, sequela
    T36.5X5A Adverse effect of aminoglycosides, initial encounter
    T36.5X5D Adverse effect of aminoglycosides, subsequent encounter
    T36.5X5S Adverse effect of aminoglycosides, sequela
    T36.6X5A Adverse effect of rifampicins, initial encounter
    T36.6X5D Adverse effect of rifampicins, subsequent encounter
    T36.6X5S Adverse effect of rifampicins, sequela
    T36.7X5A Adverse effect of antifungal antibiotics, systemically used, initial encounter
    T36.7X5D Adverse effect of antifungal antibiotics, systemically used, subsequent encounter
    T36.7X5S Adverse effect of antifungal antibiotics, systemically used, sequela
    T36.8X5A Adverse effect of other systemic antibiotics, initial encounter
    T36.8X5D Adverse effect of other systemic antibiotics, subsequent encounter
    T36.8X5S Adverse effect of other systemic antibiotics, sequela
    T36.95XA Adverse effect of unspecified systemic antibiotic, initial encounter
    T36.95XD Adverse effect of unspecified systemic antibiotic, subsequent encounter
    T36.95XS Adverse effect of unspecified systemic antibiotic, sequela
    T37.0X5A Adverse effect of sulfonamides, initial encounter
    T37.0X5D Adverse effect of sulfonamides, subsequent encounter
    T37.0X5S Adverse effect of sulfonamides, sequela
    T37.1X5A Adverse effect of antimycobacterial drugs, initial encounter
    T37.1X5D Adverse effect of antimycobacterial drugs, subsequent encounter
    T37.1X5S Adverse effect of antimycobacterial drugs, sequela
    T37.2X5A Adverse effect of antimalarials and drugs acting on other blood protozoa, initial encounter
    T37.2X5D Adverse effect of antimalarials and drugs acting on other blood protozoa, subsequent encounter
    T37.2X5S Adverse effect of antimalarials and drugs acting on other blood protozoa, sequela
    T37.3X5A Adverse effect of other antiprotozoal drugs, initial encounter
    T37.3X5D Adverse effect of other antiprotozoal drugs, subsequent encounter
    T37.3X5S Adverse effect of other antiprotozoal drugs, sequela
    T37.4X5A Adverse effect of anthelminthics, initial encounter
    T37.4X5D Adverse effect of anthelminthics, subsequent encounter
    T37.4X5S Adverse effect of anthelminthics, sequela
    T37.5X5A Adverse effect of antiviral drugs, initial encounter
    T37.5X5D Adverse effect of antiviral drugs, subsequent encounter
    T37.5X5S Adverse effect of antiviral drugs, sequela
    T37.8X5A Adverse effect of other specified systemic anti-infectives and antiparasitics, initial encounter
    T37.8X5D Adverse effect of other specified systemic anti-infectives and antiparasitics, subsequent encounter
    T37.8X5S Adverse effect of other specified systemic anti-infectives and antiparasitics, sequela
    T37.95XA Adverse effect of unspecified systemic anti-infective and antiparasitic, initial encounter
    T37.95XD Adverse effect of unspecified systemic anti-infective and antiparasitic, subsequent encounter
    T37.95XS Adverse effect of unspecified systemic anti-infective and antiparasitic, sequela
    T38.0X5A Adverse effect of glucocorticoids and synthetic analogues, initial encounter
    T38.0X5D Adverse effect of glucocorticoids and synthetic analogues, subsequent encounter
    T38.0X5S Adverse effect of glucocorticoids and synthetic analogues, sequela
    T38.1X5A Adverse effect of thyroid hormones and substitutes, initial encounter
    T38.1X5D Adverse effect of thyroid hormones and substitutes, subsequent encounter
    T38.1X5S Adverse effect of thyroid hormones and substitutes, sequela
    T38.2X5A Adverse effect of antithyroid drugs, initial encounter
    T38.2X5D Adverse effect of antithyroid drugs, subsequent encounter
    T38.2X5S Adverse effect of antithyroid drugs, sequela
    T38.4X5A Adverse effect of oral contraceptives, initial encounter
    T38.4X5D Adverse effect of oral contraceptives, subsequent encounter
    T38.4X5S Adverse effect of oral contraceptives, sequela
    T38.5X5A Adverse effect of other estrogens and progestogens, initial encounter
    T38.5X5D Adverse effect of other estrogens and progestogens, subsequent encounter
    T38.5X5S Adverse effect of other estrogens and progestogens, sequela
    T38.6X5A Adverse effect of antigonadotrophins, antiestrogens, antiandrogens, not elsewhere classified, initial encounter
    T38.6X5D Adverse effect of antigonadotrophins, antiestrogens, antiandrogens, not elsewhere classified, subsequent encounter
    T38.6X5S Adverse effect of antigonadotrophins, antiestrogens, antiandrogens, not elsewhere classified, sequela
    T38.7X5A Adverse effect of androgens and anabolic congeners, initial encounter
    T38.7X5D Adverse effect of androgens and anabolic congeners, subsequent encounter
    T38.7X5S Adverse effect of androgens and anabolic congeners, sequela
    T38.805A Adverse effect of unspecified hormones and synthetic substitutes, initial encounter
    T38.805D Adverse effect of unspecified hormones and synthetic substitutes, subsequent encounter
    T38.805S Adverse effect of unspecified hormones and synthetic substitutes, sequela
    T38.815A Adverse effect of anterior pituitary [adenohypophyseal] hormones, initial encounter
    T38.815D Adverse effect of anterior pituitary [adenohypophyseal] hormones, subsequent encounter
    T38.815S Adverse effect of anterior pituitary [adenohypophyseal] hormones, sequela
    T38.895A Adverse effect of other hormones and synthetic substitutes, initial encounter
    T38.895D Adverse effect of other hormones and synthetic substitutes, subsequent encounter
    T38.895S Adverse effect of other hormones and synthetic substitutes, sequela
    T38.905A Adverse effect of unspecified hormone antagonists, initial encounter
    T38.905D Adverse effect of unspecified hormone antagonists, subsequent encounter
    T38.905S Adverse effect of unspecified hormone antagonists, sequela
    T38.995A Adverse effect of other hormone antagonists, initial encounter
    T38.995D Adverse effect of other hormone antagonists, subsequent encounter
    T38.995S Adverse effect of other hormone antagonists, sequela
    T39.015A Adverse effect of aspirin, initial encounter
    T39.015D Adverse effect of aspirin, subsequent encounter
    T39.015S Adverse effect of aspirin, sequela
    T39.095A Adverse effect of salicylates, initial encounter
    T39.095D Adverse effect of salicylates, subsequent encounter
    T39.095S Adverse effect of salicylates, sequela
    T39.1X5A Adverse effect of 4-Aminophenol derivatives, initial encounter
    T39.1X5D Adverse effect of 4-Aminophenol derivatives, subsequent encounter
    T39.1X5S Adverse effect of 4-Aminophenol derivatives, sequela
    T39.2X5A Adverse effect of pyrazolone derivatives, initial encounter
    T39.2X5D Adverse effect of pyrazolone derivatives, subsequent encounter
    T39.2X5S Adverse effect of pyrazolone derivatives, sequela
    T39.315A Adverse effect of propionic acid derivatives, initial encounter



ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 95004, 95010 and 95015:
Covered for:
372.05
Acute atopic conjunctivitis
372.13–372.14
Chronic conjunctivitis
471.0
Polyp of nasal cavity
471.8
Other polyp of sinus
472.0
Chronic rhinitis
473.0–473.3
Chronic sinusitis
473.8–473.9
Chronic sinusitis
477.0
Allergic rhinitis due to pollen
477.2
Allergic rhinitis, due to animal (cat) (dog) hair and dander
477.8–477.9
Allergic rhinitis
478.0
Hypertrophy of nasal turbinates
493.00–493.02
Extrinsic asthma
493.20–493.22
Chronic obstructive asthma
493.90–493.92
Asthma, unspecified
691.8
Other atopic dermatitis and related conditions
693.1
Dermatitis due to food taken internally
698.9
Pruritus and related conditions, unspecified pruritic disorder
708.0–708.1
Urticaria
708.8
Other specified urticaria
989.5
Toxic effect of venom
995.0–995.1
Certain adverse effects not elsewhere classified
995.27
Other drug allergy
V14.0
Penicillin, personal history of allergy to medicinal agents
V14.7
Serum or vaccine, personal history of allergy to medicinal agents
V15.01 – V15.07
Allergy, other than to medicinal agents
Medicare is establishing the following limited coverage for CPT/HCPCS code 95024:
Covered for:
372.05
Acute atopic conjunctivitis
372.13–372.14
Chronic conjunctivitis
471.0
Polyp of nasal cavity
471.8
Other polyp of sinus
472.0
Chronic rhinitis
473.0–473.3
Chronic sinusitis
473.8–473.9
Chronic sinusitis
477.0
Allergic rhinitis
477.2
Allergic rhinitis, due to animal (cat) (dog) hair and dander
477.8–477.9
Allergic rhinitis due to other allergen
478.0
Hypertrophy of nasal turbinates
493.00–493.02
Extrinsic asthma
493.20–493.22
Chronic obstructive asthma
493.90–493.92
Asthma, unspecified
691.8
Other atopic dermatitis and related conditions
698.9
Pruritus and related conditions, unspecified pruritic disorder
708.0–708.1
Urticaria
708.8
Other specified urticaria
989.5
Toxic effect of venom
995.0–995.1
Certain adverse effects not elsewhere classified
995.27
Other drug allergy
V14.0 – V14.3
Personal history of allergy to medicinal agents
V14.7
Personal history of allergy to medicinal agents
V15.06 – V15.07
Allergy, other than to medicinal agents
Medicare is establishing the following limited coverage for CPT/HCPCS code 95044:
Covered for:
692.0–692.6
Contact dermatitis and other eczema
692.81
Dermatitis due to cosmetics
692.83–692.84
Contact dermatitis and other eczema
692.89
Contact dermatitis and other eczema due to other specified agents
692.9
Contact dermatitis and other eczema unspecified cause
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
Documentation must demonstrate that allergy testing has been performed in accordance within the indications and limitations of this policy.
Documentation should reflect failure of previous patch testing to elucidate the etiology of the allergic dermatitis and should be made available upon request.
Appendices
N/A
Utilization Guidelines
  • The selection of antigens should be individualized, based on the history and physical examination.
  • Medicare expects that all patients will not be tested for the same antigens or receive the same number/type of tests.
  • Medicare would not expect that more than 75 percutaneous tests per year are medically necessary for the management of an individual patient. More than 75 tests per year may be allowed upon review when the clinical circumstances documented in the patient’s medical record substantiate the need for additional tests.
  • Medicare would not expect that more than 20 intradermal tests per year are medically necessary for the management of an individual patient. More than 20 tests per year may be allowed upon review when the clinical circumstances documented in the patient’s medical record substantiate the need for additional tests.
  • Medicare would not expect allergy patch testing to be routinely done on an annual basis. Rather it should be reserved for those patients whose occupational or environmental exposures have caused an allergic contact dermatitis, the cause of which cannot be determined by usual historical or clinical means.
  • Medicare would not expect that more than 30 patch tests (a standard series of 24 allergens with controls or individual patch test allergens) per beneficiary per year is medically necessary for the management of an individual patient. The medical necessity of the frequency of patch testing must be documented in the medical record.
Notice: This LCD imposes utilization guideline limitations. Despite Medicare’s allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services.
Sources of Information and Basis for Decision
J4 (CO, NM, OK, TX) MAC Consolidation
TrailBlazer adopted the TrailBlazer LCD, “Allergy Skin Testing,” with patch test provisions from Pinnacle’s stand alone “Allergy Patch Test” LCD. This integrated TrailBlazer LCD is for the Jurisdiction 4 (J4) MAC transition.
Full disclosure of information sources is found with original contractor LCDs.