A Review of Non-covered Allergy Testing and Treatment Methods
For BCBSOK providers who perform allergy testing and/or treatment, it is important to note that Serial Dilution Endpoint Titration/Serial Endpoint Titration (SDET/SET) and Sublingual Immunotherapy (SLIT) are services that are not covered by BCBSOK.
SDET/SET is a form of intradermal skin testing that uses increasing doses of antigen to determine the concentration at which the reaction changes from negative to positive (the "endpoint"). SDET/SET has been used to guide the initiation of immunotherapy, by using the endpoint dilution as the starting antigen dose. BCBSOK medical policy MED206.001 (Allergy Management) clearly specifies this type of allergy testing to be experimental, investigational and unproven, and, as such, is a non-covered service. The Current Procedural Terminology (CPT® code) most often used to bill for this non-covered service is 95028 [Intracutaneous (intradermal) tests with allergenic extracts]. While 95028 is a valid code, when billed to induce payment for a non-covered service, it is considered an intentional misrepresentation of the services provided and as such constitutes a fraudulent act.
SLIT is a form of allergy treatment where antigen serum is administered (often self-administered by the patient) by placing a few drops of the serum under the patient’s tongue. BCBSOK medical policy MED206.001 (Allergy Management) clearly specifies this type of allergy treatment to be experimental, investigational and unproven, and, as such, is a non-covered service. The CPT code most often used to bill for this non-covered service is 95165 (Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy). CPT defines allergen immunotherapy as "the parenteral (administered in a manner other than through the digestive tract, as by intravenous or intramuscular injection) administration of allergenic extracts." While 95165 is a valid code, when billed to induce payment for SLIT or other non-covered service, it is considered an intentional misrepresentation of the services provided and as such constitutes a fraudulent act.
See below for additional methods of allergy testing and treatment that are considered by BCBSOK medical policy to be experimental, investigational and unproven and, as such, are non-covered services.
Non-covered Allergy Testing Methods
- Provocative tests for food or food additive allergies
- Neutralization testing
- Serial dilution endpoint titration (SDET), serial endpoint titration (SET), Rinkle/Rinkle method
- Nasal challenge tests
- Conjunctival challenge test (ophthalmic mucous membrane test)
- Cytotoxic food tests (Bryan’s test)
- Leukocyte histamine release test (LHRT)
- Rebuck skin window test
- Passive transfer or P-X (Prausnitz-Kustner test)
- Antigen leukocyte cellular antibody test (ALCAT)
- Sublingual provocation food testing
- IgE concentration food allergy testing
- IgG food and environmental testing
- Any aspect of the Lifestyle Eating and Performance (LEAP) program, including the Mediator Release Test (MRT) used to identify "delayed food allergies" and treatments which include dietary manipulation and/or supplements or herbs
Non-covered Allergy Treatment Methods
- Provocative and neutralization therapy, using intradermal and subcutaneous routes
- Sublingual: oral application of natural or enzymatically altered antigens
- Topical: localized application of an allergen directly to the organ creating the allergy response, such as the nose for allergic rhinitis
- Urine auto-injections (autogenous urine immunization): freshly collected urine, having been sterilized and filtrated, injected to the donating patient
- Repository emulsion therapy - solutions of vegetable and mineral oils containing additional allergens, to produce slow releases of the allergens at the injection site
- Intracutaneous (intradermal) tests, sequential and incremental [Serial dilution endpoint titration (SDET) therapy (Rinkel/Rinkle Method)].
For more details, please refer to our Medical Policies.
If you have knowledge of fraudulent activity, please contact the BCBSOK Fraud Hotline at (800) 543-0867 or report fraud online. Reports may be made anonymously, if desired.
Current Procedural Terminology (CPT® ), copyright 2008, by the American Medical Association (AMA). CPT is a registered trademark of the AMA.