Aetna · Clinical coverage policy

Aetna Allergy Testing and Immunotherapy coverage criteria

Aetna CPB 0038 covers allergy and hypersensitivity testing and immunotherapy when symptoms are not controlled by conservative therapy and testing correlates to the member's history, exposure risk, and physical findings, using techniques with proven peer-reviewed efficacy. Covered services include skin (prick/intradermal/patch) and validated in vitro IgE tests for IgE-mediated allergies, plus allergy immunotherapy, rapid desensitization, epinephrine kits, and aspirin desensitization for specific qualifying indications. A large list of alternative/unvalidated tests and treatments (e.g., ALCAT, IgG/IgG4 food testing, cytotoxic testing, provocation-neutralization, electrodermal testing, applied kinesiology) and several non-allergic indications are deemed experimental/investigational or not medically necessary; the bulletin is silent on precertification.

Policy CPB 0038 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0038

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0038 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Allergy Testing and Immunotherapy (CPT 95004), and what gets it denied?

Path
Aetna CPB 0038 covers allergy and hypersensitivity testing and immunotherapy when symptoms are not controlled by conservative therapy and testing correlates to the member's history, exposure risk, and physical findings, using techniques with proven peer-reviewed efficacy. Covered services include skin (prick/intradermal/patch) and validated in vitro IgE tests for IgE-mediated allergies, plus allergy immunotherapy, rapid desensitization, epinephrine kits, and aspirin desensitization for specific qualifying indications. A large list of alternative/unvalidated tests and treatments (e.g., ALCAT, IgG/IgG4 food testing, cytotoxic testing, provocation-neutralization, electrodermal testing, applied kinesiology) and several non-allergic indications are deemed experimental/investigational or not medically necessary; the bulletin is silent on precertification. Coverage criteria include: General allergy testing requirement (ALL of): symptoms are not adequately controlled by empiric conservative therapy; AND testing must correlate specifically to the member's history, risk of exposure and physical findings; AND test technique and/or allergens tested must have proven efficacy demonstrated through scientifically valid medical studies published in the peer-reviewed literature; Epicutaneous (scratch, prick, puncture) testing medically necessary when IgE-mediated reactions occur to ONE of: foods, hymenoptera (stinging insects), inhalants, or specific drugs (penicillins and macromolecular agents); Intradermal (intracutaneous) testing medically necessary when IgE-mediated reactions occur to ONE of: hymenoptera venom allergy, inhalants, or specific drugs (penicillins and macromolecular agents); Allergy testing quantity: up to 70 percutaneous tests may be required, followed by up to 40 intracutaneous tests when percutaneous tests are negative; Skin endpoint titration (SET / intradermal dilutional testing) medically necessary for determining the starting dose of immunotherapy for ONE of: highly allergic members to hymenoptera venom OR highly allergic members to inhalants; up to 14 titration tests may be necessary, with an additional 40 antigens or 80 IDT injections medically necessary if initial results are positive; Skin patch testing medically necessary for diagnosing contact allergic dermatitis (up to 80 units considered medically necessary); Photo patch testing medically necessary for diagnosing photo-allergy (e.g., photo-allergic contact dermatitis); Photo tests medically necessary for evaluating photo-sensitivity disorders; Bronchial challenge testing (with methacholine, histamine, or antigens) medically necessary for defining asthma or airway hyperactivity when ONE of: testing identifies new allergens for which skin or blood testing is not validated, OR skin testing is unreliable; Exercise challenge testing medically necessary for exercise-induced bronchospasm; Ingestion (oral) challenge testing medically necessary for ONE of: food or other substances (e.g., metabisulfite); OR drugs when ALL of following met: history of drug allergy, no effective alternative drug available, AND treatment with that drug class is essential; In vitro IgE antibody tests (RAST, MAST, FAST, ELISA, ImmunoCAP) medically necessary when ONE of: patient is receiving skin-test suppressive medication (antihistamines, beta blockers) that cannot be temporarily discontinued; widespread skin disease (dermatographism, ichthyosis, intensive dermatitis, generalized eczema); uncooperative patients (small children, mental/physical impairments); clinical history suggests unusually greater anaphylaxis risk from skin testing; OR evaluating cross-reactivity between insect venoms; In vitro IgE antibody tests medically necessary as an adjunctive laboratory test for disease activity of: allergic bronchopulmonary aspergillosis (ABPA) or certain parasitic diseases; In vitro IgE antibody testing medically necessary for ONE of: ABPA and parasitic diseases, food allergy, hymenoptera venom allergy, inhalant allergy, or specific drugs; In vitro IgE initial allergy screen: 40 tests for inhalant allergies and 12 tests for food/other allergies medically necessary; additional tests medically necessary if initial results positive; if all initial results negative, no further testing beyond the initial screen is considered medically necessary; Total serum IgE (PRIST, RIST) medically necessary for diagnostic evaluation in members with known or suspected ABPA and/or hyper-IgE syndrome; Lymphocyte transformation tests medically necessary for evaluating persons with sensitivity to beryllium; Lymphocyte transformation tests medically necessary for evaluation of congenital or acquired immunodeficiency diseases affecting cell-mediated immunity (e.g., severe combined immunodeficiency, common variable immunodeficiency, X-linked immunodeficiency with hyper-IgM, Nijmegen breakage syndrome, reticular dysgenesis, DiGeorge syndrome, Nezelof syndrome, Wiscott-Aldrich syndrome, ataxia telangiectasia, chronic mucocutaneous candidiasis); Lymphocyte transformation tests medically necessary for evaluation of persons with thymoma; Lymphocyte transformation tests medically necessary to predict allograft compatibility in the transplant setting; Alpha-gal (mammalian meat) allergy testing for IgE antibodies specific for alpha-gal medically necessary for individuals presenting with documentation of ONE of the following after mammalian meat ingestion (typically 3-6 hours): urticaria, angioedema, or anaphylaxis; OR gastrointestinal symptoms (abdominal pain, diarrhea, vomiting) accompanied by pre-syncope or syncope; Ara h 2 testing medically necessary for persons with suspected peanut allergy; Repeat percutaneous allergy testing may be performed if ONE of: new sensitivities develop during/after allergen immunotherapy, OR the person failed to respond to allergen immunotherapy; Serum tryptase testing medically necessary for evaluation of suspected anaphylaxis and suspected mast cell disorders; Tryptase gene copy number analysis medically necessary for evaluation of ONE of: unexplained elevated basal serum tryptase, suspected hereditary alpha tryptasemia, mastocytosis, or recurrent anaphylaxis; Allergy immunotherapy medically necessary when administered in a medical facility for treatment of IgE-mediated allergies to ONE of: allergic (extrinsic) asthma, dust mite atopic dermatitis, hymenoptera (bees, hornets, wasps, fire ants), mold-induced allergic rhinitis, perennial rhinitis, or seasonal allergic rhinitis or conjunctivitis; Allergy immunotherapy: member must meet ONE of the following indications: (a) member has severe seasonal or perennial IgE-dependent symptoms of allergic rhinoconjunctivitis or asthma after natural allergen exposure AND BOTH (skin test and/or serologic evidence of IgE-mediated antibody to a potent allergen extract) AND (avoidance or pharmacologic therapy cannot control symptoms OR member has unacceptable side effects with pharmacologic therapy); (b) member has life-threatening IgE-mediated allergy to insect stings (bees, hornets, wasps, fire ants); or (c) hypersensitivity to allergens that cannot be managed by medication or avoidance; Sublingual immunotherapy covered ONLY for: Oralair (grass pollen), Grastek (grass pollen), or Ragwitek (ragweed pollen); Rapid desensitization (rush, cluster, acute desensitization) medically necessary for members with ONE of: allergy to a particular drug not effectively treated with alternatives; insect sting hypersensitivity (hymenoptera); or moderate to severe allergic rhinitis needing treatment during/immediately before allergy season when avoidance/pharmacotherapy has failed; allergens must be individually prepared based on appropriate skin or in vitro testing; Rapid desensitization is an acceptable approach if a woman contemplating pregnancy requires initiation of allergy immunotherapy and/or has an anticipated need for allergy medications that would increase risk to the fetus; Epinephrine kits (Ana-Kit, Epi-Pen auto-injectors) medically necessary to prevent anaphylactic shock for individuals with ONE of: life-threatening reactions to insect stings, foods, drugs, or other allergens; severe asthma; or if needed during immunotherapy; Aspirin desensitization medically necessary for aspirin-sensitive persons requiring ASA/ASA-like drugs (where aspirin avoidance is not possible) in the setting of ONE of: chronic rhinosinusitis with nasal polyposis refractory to topical glucocorticoids/leukotriene-modifying agents/other therapies; stable cardiovascular disease or cardiovascular risk factors requiring aspirin antiplatelet therapy; need for NSAIDs for chronic inflammatory conditions (e.g., arthritis); antiphospholipid syndromes during pregnancy; or poorly controlled asthma. Applies to 30 codes: 95004, 95017, 95018, 95024, 95027, 95028, 95044, 95070, 95076, 95079, 86003, 86005, 86008, 82785, 95115, 95117, 95120, 95125, 95130, 95131, 95132, 95134, 95144, 95145, 95146, 95147, 95148, 95165, 95170, 95180.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source.
Trap
Policy exclusions and limitations: ALCAT test (automated food allergy test) - experimental/investigational/unproven; Allergen-specific IgG (RAST/ELISA) testing - unproven for allergy evaluation; Allergenex testing - unproven for rhinitis and all other indications; Allergy testing and desensitization for poison ivy, oak and sumac - unproven; Anti-Fc epsilon receptor antibodies testing - unproven; Anti-IgE receptor antibody testing - unproven; Atopy patch testing - unproven for diagnosis of food protein-induced enterocolitis syndrome (FPIES) and non-IgE gastrointestinal food allergy; Basophil activation test (BAT) - unproven; Body chemical analysis - unproven; Candidiasis test - unproven; Chlorinated pesticides (serum) - unproven; Chronic Urticaria Index testing - unproven; Clifford materials reactivity testing - unproven; Complement (total or components) - unproven for allergy (may be appropriate in autoimmune disorders, complement component deficiencies, hereditary angioedema, vasculitis); Complement antigen testing - unproven; Component-derived (component-resolved) diagnostic testing (CRD) - unproven for food allergy evaluation, except alpha-gal and Ara h 2 testing; C-reactive protein - unproven for allergy (may be appropriate in inflammatory diseases); Cytokine and cytokine receptor assay - unproven; Cytotoxic food testing (Bryans Test, ACT) - unproven; Cytotoxic testing (Bryans Test) - unproven for food sensitivity/allergy; Electrodermal acupuncture - unproven; Electrodermal testing - unproven for food sensitivity/allergy; ELISA/ACT - unproven; Eosinophil cationic protein (ECP) test - unproven; Food immune complex assays (FICA) - unproven; Food-specific IgG antibodies - unproven; Genetic testing for food allergy - unproven; IgG testing - unproven for food sensitivity/allergy; IgG4 testing - unproven for evaluation of allergy; Immune complex assay - unproven for allergy (may be appropriate in autoimmune disorders, systemic lupus erythematosus, vasculitis); Immune complex testing - unproven for food sensitivity/allergy; Infinite Allergy Labs' Food Allergy Sensitivity Test (FAST) panel - unproven; In-vitro metal allergy testing (lymphocyte transformation tests, LTT) - unproven / not medically necessary; In vitro histamine release testing (leukocyte histamine release test) - unproven; In vitro lymphocyte proliferation test - unproven; Leukocyte antibodies testing - unproven; Lymphocytes (B or T subsets) - unproven for allergy (may be appropriate for collagen vascular disease, immune deficiency syndromes, leukemia, lymphomas); Lymphocyte function assay - unproven; Lymphocyte or basophil phenotyping - unproven for food allergy; Mediator release test (MRT) - unproven; Muscle strength testing or measurement (kinesiology) after allergen ingestion - unproven; Ophthalmic mucous membrane tests / conjunctival challenge tests - unproven; Prausnitz-Kustner (P-K) testing / passive cutaneous transfer test - unproven; contraindicated due to risk of transmitting hepatitis or AIDS; Provocative nasal test (nasal provocation testing) - unproven; Provocation-neutralization testing (Rinkel Test), whether subcutaneous or sublingual - unproven; Pulse test (pulse response test, reaginic pulse test) - unproven; Rebuck skin window test - unproven; Routine percutaneous allergy testing after allergen immunotherapy - not medically necessary unless new symptoms, failure of improvement, or return of symptoms after the immunotherapy course; Serum immunoglobulin A (IgA) and immunoglobulin G (IgG) testing - unproven for allergy; Skin patch testing - not medically necessary for irritable bowel syndrome; Sublingual provocative neutralization testing and treatment with hormones - unproven; Testing for electromagnetic sensitivity syndrome/disorder (a.k.a. allergy to electricity, electro-sensitivity, electro-hypersensitivity) - unproven; Testing for food-specific IgE to identify food triggers of FPIES - unproven; Testing for multiple chemical sensitivity syndrome (a.k.a. idiopathic environmental intolerance / IEI, clinical ecological illness, environmental illness, chemical AIDS, total allergy syndrome, cerebral allergy, 20th century disease) - unproven; Tests of lymphocyte activation - unproven for food sensitivity/allergy; Venom blocking antibodies - unproven; VeriMAP Peanut DX - unproven; Volatile chemical panels (blood testing for chemicals) - unproven; Acupuncture - unproven for allergies; Allergoids (modification of allergens to reduce allergenicity) - unproven; Allergy immunotherapy for angioedema - unproven; Allergy immunotherapy for atopic dermatitis (except dust mite atopic dermatitis) - unproven; Allergy immunotherapy for chronic urticaria - unproven; Allergy immunotherapy for food allergy (except FDA-approved peanut OIT per CPB 0968) - unproven; Allergy immunotherapy for intrinsic (non-allergic) asthma - unproven; Allergy immunotherapy for migraine headaches - unproven; Allergy immunotherapy for non-allergic vasomotor rhinitis - unproven; Allergy immunotherapy for tree nut allergy - unproven; Autogenous urine immunization (autogenous urine therapy) - unproven; Autologous whole-blood or autologous serum acupoint injection - unproven for treatment of chronic urticaria; Bacterial immunotherapy - unproven; Chemical cautery of nasal mucosa - unproven for treatment of allergic rhinitis; Detoxification - unproven for allergies; Ecology units / environmental control units / environmental chemical avoidance - unproven for multiple chemical sensitivity syndrome; Enzyme potentiated desensitization (EPD) - unproven; Helminth Trichuris suis therapy - unproven for allergic rhinitis; Home administration of allergy immunotherapy - not medically necessary / not covered; Homeopathy - unproven for allergies; Intradermal grass pollen immunotherapy - unproven for treatment of allergic rhinitis / not covered; Intramuscular (IM) steroids - not medically necessary for treatment of acute sinusitis and allergic rhinitis; Intranasal immunotherapy - not medically necessary / not covered; Mechanical allergen particle barrier / inhalation filter, cream, nasal, topical (e.g., Alzair Allergy Blocker) - unproven; Neutralization therapy (desensitization neutralization therapy) - unproven; Neutralizing therapy of chemical and food extracts - unproven; Oral immunotherapy (OIT) for egg allergy and food allergy (except FDA-approved OIT for peanut allergy) - unproven; Oral nystatin - unproven for treatment of candidiasis hypersensitivity syndrome; Photo-inactivated extracts - unproven; Polymerized extracts - unproven; Poison ivy / poison oak extracts - unproven for immunotherapy in prevention of toxicodendron (Rhus) dermatitis; Probiotics - unproven for food allergy prevention or treatment; Quantitative bradykinin - unproven; Repository emulsion therapy - unproven; Rhino-phototherapy - unproven; Subcutaneous steroids - not medically necessary for treatment of allergic rhinitis; Sublingual drops / sublingual immunotherapy - unproven except Oralair, Grastek, and Ragwitek; Sublingual immunotherapy - not medically necessary for asthmatic children sensitized to house dust mite; Treatments for electromagnetic sensitivity syndrome/disorder - unproven; Ultra low dose enzyme activated immunotherapy (low dose allergens / LDA) - unproven; Routine allergy re-testing - not medically necessary; Performance of both percutaneous allergy tests and IgE RAST (blood) tests for the same allergens - not medically necessary; Repeated percutaneous allergy testing for monitoring response to immunotherapy - not medically necessary; Intradermal (intracutaneous) testing for food allergy diagnosis - not appropriate due to high false-positive rate and anaphylaxis risk; Skin endpoint titration (SET) used in place of skin testing - inappropriate. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source: Aetna CPB 0038 — Allergy Testing and Immunotherapy

Coverage criteria

  • General allergy testing requirement (ALL of): symptoms are not adequately controlled by empiric conservative therapy; AND testing must correlate specifically to the member's history, risk of exposure and physical findings; AND test technique and/or allergens tested must have proven efficacy demonstrated through scientifically valid medical studies published in the peer-reviewed literature
  • Epicutaneous (scratch, prick, puncture) testing medically necessary when IgE-mediated reactions occur to ONE of: foods, hymenoptera (stinging insects), inhalants, or specific drugs (penicillins and macromolecular agents)
  • Intradermal (intracutaneous) testing medically necessary when IgE-mediated reactions occur to ONE of: hymenoptera venom allergy, inhalants, or specific drugs (penicillins and macromolecular agents)
  • Allergy testing quantity: up to 70 percutaneous tests may be required, followed by up to 40 intracutaneous tests when percutaneous tests are negative
  • Skin endpoint titration (SET / intradermal dilutional testing) medically necessary for determining the starting dose of immunotherapy for ONE of: highly allergic members to hymenoptera venom OR highly allergic members to inhalants; up to 14 titration tests may be necessary, with an additional 40 antigens or 80 IDT injections medically necessary if initial results are positive
  • Skin patch testing medically necessary for diagnosing contact allergic dermatitis (up to 80 units considered medically necessary)
  • Photo patch testing medically necessary for diagnosing photo-allergy (e.g., photo-allergic contact dermatitis)
  • Photo tests medically necessary for evaluating photo-sensitivity disorders
  • Bronchial challenge testing (with methacholine, histamine, or antigens) medically necessary for defining asthma or airway hyperactivity when ONE of: testing identifies new allergens for which skin or blood testing is not validated, OR skin testing is unreliable
  • Exercise challenge testing medically necessary for exercise-induced bronchospasm
  • Ingestion (oral) challenge testing medically necessary for ONE of: food or other substances (e.g., metabisulfite); OR drugs when ALL of following met: history of drug allergy, no effective alternative drug available, AND treatment with that drug class is essential
  • In vitro IgE antibody tests (RAST, MAST, FAST, ELISA, ImmunoCAP) medically necessary when ONE of: patient is receiving skin-test suppressive medication (antihistamines, beta blockers) that cannot be temporarily discontinued; widespread skin disease (dermatographism, ichthyosis, intensive dermatitis, generalized eczema); uncooperative patients (small children, mental/physical impairments); clinical history suggests unusually greater anaphylaxis risk from skin testing; OR evaluating cross-reactivity between insect venoms
  • In vitro IgE antibody tests medically necessary as an adjunctive laboratory test for disease activity of: allergic bronchopulmonary aspergillosis (ABPA) or certain parasitic diseases
  • In vitro IgE antibody testing medically necessary for ONE of: ABPA and parasitic diseases, food allergy, hymenoptera venom allergy, inhalant allergy, or specific drugs
  • In vitro IgE initial allergy screen: 40 tests for inhalant allergies and 12 tests for food/other allergies medically necessary; additional tests medically necessary if initial results positive; if all initial results negative, no further testing beyond the initial screen is considered medically necessary
  • Total serum IgE (PRIST, RIST) medically necessary for diagnostic evaluation in members with known or suspected ABPA and/or hyper-IgE syndrome
  • Lymphocyte transformation tests medically necessary for evaluating persons with sensitivity to beryllium
  • Lymphocyte transformation tests medically necessary for evaluation of congenital or acquired immunodeficiency diseases affecting cell-mediated immunity (e.g., severe combined immunodeficiency, common variable immunodeficiency, X-linked immunodeficiency with hyper-IgM, Nijmegen breakage syndrome, reticular dysgenesis, DiGeorge syndrome, Nezelof syndrome, Wiscott-Aldrich syndrome, ataxia telangiectasia, chronic mucocutaneous candidiasis)
  • Lymphocyte transformation tests medically necessary for evaluation of persons with thymoma
  • Lymphocyte transformation tests medically necessary to predict allograft compatibility in the transplant setting
  • Alpha-gal (mammalian meat) allergy testing for IgE antibodies specific for alpha-gal medically necessary for individuals presenting with documentation of ONE of the following after mammalian meat ingestion (typically 3-6 hours): urticaria, angioedema, or anaphylaxis; OR gastrointestinal symptoms (abdominal pain, diarrhea, vomiting) accompanied by pre-syncope or syncope
  • Ara h 2 testing medically necessary for persons with suspected peanut allergy
  • Repeat percutaneous allergy testing may be performed if ONE of: new sensitivities develop during/after allergen immunotherapy, OR the person failed to respond to allergen immunotherapy
  • Serum tryptase testing medically necessary for evaluation of suspected anaphylaxis and suspected mast cell disorders
  • Tryptase gene copy number analysis medically necessary for evaluation of ONE of: unexplained elevated basal serum tryptase, suspected hereditary alpha tryptasemia, mastocytosis, or recurrent anaphylaxis
  • Allergy immunotherapy medically necessary when administered in a medical facility for treatment of IgE-mediated allergies to ONE of: allergic (extrinsic) asthma, dust mite atopic dermatitis, hymenoptera (bees, hornets, wasps, fire ants), mold-induced allergic rhinitis, perennial rhinitis, or seasonal allergic rhinitis or conjunctivitis
  • Allergy immunotherapy: member must meet ONE of the following indications: (a) member has severe seasonal or perennial IgE-dependent symptoms of allergic rhinoconjunctivitis or asthma after natural allergen exposure AND BOTH (skin test and/or serologic evidence of IgE-mediated antibody to a potent allergen extract) AND (avoidance or pharmacologic therapy cannot control symptoms OR member has unacceptable side effects with pharmacologic therapy); (b) member has life-threatening IgE-mediated allergy to insect stings (bees, hornets, wasps, fire ants); or (c) hypersensitivity to allergens that cannot be managed by medication or avoidance
  • Sublingual immunotherapy covered ONLY for: Oralair (grass pollen), Grastek (grass pollen), or Ragwitek (ragweed pollen)
  • Rapid desensitization (rush, cluster, acute desensitization) medically necessary for members with ONE of: allergy to a particular drug not effectively treated with alternatives; insect sting hypersensitivity (hymenoptera); or moderate to severe allergic rhinitis needing treatment during/immediately before allergy season when avoidance/pharmacotherapy has failed; allergens must be individually prepared based on appropriate skin or in vitro testing
  • Rapid desensitization is an acceptable approach if a woman contemplating pregnancy requires initiation of allergy immunotherapy and/or has an anticipated need for allergy medications that would increase risk to the fetus
  • Epinephrine kits (Ana-Kit, Epi-Pen auto-injectors) medically necessary to prevent anaphylactic shock for individuals with ONE of: life-threatening reactions to insect stings, foods, drugs, or other allergens; severe asthma; or if needed during immunotherapy
  • Aspirin desensitization medically necessary for aspirin-sensitive persons requiring ASA/ASA-like drugs (where aspirin avoidance is not possible) in the setting of ONE of: chronic rhinosinusitis with nasal polyposis refractory to topical glucocorticoids/leukotriene-modifying agents/other therapies; stable cardiovascular disease or cardiovascular risk factors requiring aspirin antiplatelet therapy; need for NSAIDs for chronic inflammatory conditions (e.g., arthritis); antiphospholipid syndromes during pregnancy; or poorly controlled asthma

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Frequently asked questions

When does Aetna cover Allergy Testing and Immunotherapy (CPT 95004), and what gets it denied?
Aetna CPB 0038 covers allergy and hypersensitivity testing and immunotherapy when symptoms are not controlled by conservative therapy and testing correlates to the member's history, exposure risk, and physical findings, using techniques with proven peer-reviewed efficacy. Covered services include skin (prick/intradermal/patch) and validated in vitro IgE tests for IgE-mediated allergies, plus allergy immunotherapy, rapid desensitization, epinephrine kits, and aspirin desensitization for specific qualifying indications. A large list of alternative/unvalidated tests and treatments (e.g., ALCAT, IgG/IgG4 food testing, cytotoxic testing, provocation-neutralization, electrodermal testing, applied kinesiology) and several non-allergic indications are deemed experimental/investigational or not medically necessary; the bulletin is silent on precertification. Coverage criteria include: General allergy testing requirement (ALL of): symptoms are not adequately controlled by empiric conservative therapy; AND testing must correlate specifically to the member's history, risk of exposure and physical findings; AND test technique and/or allergens tested must have proven efficacy demonstrated through scientifically valid medical studies published in the peer-reviewed literature; Epicutaneous (scratch, prick, puncture) testing medically necessary when IgE-mediated reactions occur to ONE of: foods, hymenoptera (stinging insects), inhalants, or specific drugs (penicillins and macromolecular agents); Intradermal (intracutaneous) testing medically necessary when IgE-mediated reactions occur to ONE of: hymenoptera venom allergy, inhalants, or specific drugs (penicillins and macromolecular agents); Allergy testing quantity: up to 70 percutaneous tests may be required, followed by up to 40 intracutaneous tests when percutaneous tests are negative; Skin endpoint titration (SET / intradermal dilutional testing) medically necessary for determining the starting dose of immunotherapy for ONE of: highly allergic members to hymenoptera venom OR highly allergic members to inhalants; up to 14 titration tests may be necessary, with an additional 40 antigens or 80 IDT injections medically necessary if initial results are positive; Skin patch testing medically necessary for diagnosing contact allergic dermatitis (up to 80 units considered medically necessary); Photo patch testing medically necessary for diagnosing photo-allergy (e.g., photo-allergic contact dermatitis); Photo tests medically necessary for evaluating photo-sensitivity disorders; Bronchial challenge testing (with methacholine, histamine, or antigens) medically necessary for defining asthma or airway hyperactivity when ONE of: testing identifies new allergens for which skin or blood testing is not validated, OR skin testing is unreliable; Exercise challenge testing medically necessary for exercise-induced bronchospasm; Ingestion (oral) challenge testing medically necessary for ONE of: food or other substances (e.g., metabisulfite); OR drugs when ALL of following met: history of drug allergy, no effective alternative drug available, AND treatment with that drug class is essential; In vitro IgE antibody tests (RAST, MAST, FAST, ELISA, ImmunoCAP) medically necessary when ONE of: patient is receiving skin-test suppressive medication (antihistamines, beta blockers) that cannot be temporarily discontinued; widespread skin disease (dermatographism, ichthyosis, intensive dermatitis, generalized eczema); uncooperative patients (small children, mental/physical impairments); clinical history suggests unusually greater anaphylaxis risk from skin testing; OR evaluating cross-reactivity between insect venoms; In vitro IgE antibody tests medically necessary as an adjunctive laboratory test for disease activity of: allergic bronchopulmonary aspergillosis (ABPA) or certain parasitic diseases; In vitro IgE antibody testing medically necessary for ONE of: ABPA and parasitic diseases, food allergy, hymenoptera venom allergy, inhalant allergy, or specific drugs; In vitro IgE initial allergy screen: 40 tests for inhalant allergies and 12 tests for food/other allergies medically necessary; additional tests medically necessary if initial results positive; if all initial results negative, no further testing beyond the initial screen is considered medically necessary; Total serum IgE (PRIST, RIST) medically necessary for diagnostic evaluation in members with known or suspected ABPA and/or hyper-IgE syndrome; Lymphocyte transformation tests medically necessary for evaluating persons with sensitivity to beryllium; Lymphocyte transformation tests medically necessary for evaluation of congenital or acquired immunodeficiency diseases affecting cell-mediated immunity (e.g., severe combined immunodeficiency, common variable immunodeficiency, X-linked immunodeficiency with hyper-IgM, Nijmegen breakage syndrome, reticular dysgenesis, DiGeorge syndrome, Nezelof syndrome, Wiscott-Aldrich syndrome, ataxia telangiectasia, chronic mucocutaneous candidiasis); Lymphocyte transformation tests medically necessary for evaluation of persons with thymoma; Lymphocyte transformation tests medically necessary to predict allograft compatibility in the transplant setting; Alpha-gal (mammalian meat) allergy testing for IgE antibodies specific for alpha-gal medically necessary for individuals presenting with documentation of ONE of the following after mammalian meat ingestion (typically 3-6 hours): urticaria, angioedema, or anaphylaxis; OR gastrointestinal symptoms (abdominal pain, diarrhea, vomiting) accompanied by pre-syncope or syncope; Ara h 2 testing medically necessary for persons with suspected peanut allergy; Repeat percutaneous allergy testing may be performed if ONE of: new sensitivities develop during/after allergen immunotherapy, OR the person failed to respond to allergen immunotherapy; Serum tryptase testing medically necessary for evaluation of suspected anaphylaxis and suspected mast cell disorders; Tryptase gene copy number analysis medically necessary for evaluation of ONE of: unexplained elevated basal serum tryptase, suspected hereditary alpha tryptasemia, mastocytosis, or recurrent anaphylaxis; Allergy immunotherapy medically necessary when administered in a medical facility for treatment of IgE-mediated allergies to ONE of: allergic (extrinsic) asthma, dust mite atopic dermatitis, hymenoptera (bees, hornets, wasps, fire ants), mold-induced allergic rhinitis, perennial rhinitis, or seasonal allergic rhinitis or conjunctivitis; Allergy immunotherapy: member must meet ONE of the following indications: (a) member has severe seasonal or perennial IgE-dependent symptoms of allergic rhinoconjunctivitis or asthma after natural allergen exposure AND BOTH (skin test and/or serologic evidence of IgE-mediated antibody to a potent allergen extract) AND (avoidance or pharmacologic therapy cannot control symptoms OR member has unacceptable side effects with pharmacologic therapy); (b) member has life-threatening IgE-mediated allergy to insect stings (bees, hornets, wasps, fire ants); or (c) hypersensitivity to allergens that cannot be managed by medication or avoidance; Sublingual immunotherapy covered ONLY for: Oralair (grass pollen), Grastek (grass pollen), or Ragwitek (ragweed pollen); Rapid desensitization (rush, cluster, acute desensitization) medically necessary for members with ONE of: allergy to a particular drug not effectively treated with alternatives; insect sting hypersensitivity (hymenoptera); or moderate to severe allergic rhinitis needing treatment during/immediately before allergy season when avoidance/pharmacotherapy has failed; allergens must be individually prepared based on appropriate skin or in vitro testing; Rapid desensitization is an acceptable approach if a woman contemplating pregnancy requires initiation of allergy immunotherapy and/or has an anticipated need for allergy medications that would increase risk to the fetus; Epinephrine kits (Ana-Kit, Epi-Pen auto-injectors) medically necessary to prevent anaphylactic shock for individuals with ONE of: life-threatening reactions to insect stings, foods, drugs, or other allergens; severe asthma; or if needed during immunotherapy; Aspirin desensitization medically necessary for aspirin-sensitive persons requiring ASA/ASA-like drugs (where aspirin avoidance is not possible) in the setting of ONE of: chronic rhinosinusitis with nasal polyposis refractory to topical glucocorticoids/leukotriene-modifying agents/other therapies; stable cardiovascular disease or cardiovascular risk factors requiring aspirin antiplatelet therapy; need for NSAIDs for chronic inflammatory conditions (e.g., arthritis); antiphospholipid syndromes during pregnancy; or poorly controlled asthma. Applies to 30 codes: 95004, 95017, 95018, 95024, 95027, 95028, 95044, 95070, 95076, 95079, 86003, 86005, 86008, 82785, 95115, 95117, 95120, 95125, 95130, 95131, 95132, 95134, 95144, 95145, 95146, 95147, 95148, 95165, 95170, 95180. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Policy exclusions and limitations: ALCAT test (automated food allergy test) - experimental/investigational/unproven; Allergen-specific IgG (RAST/ELISA) testing - unproven for allergy evaluation; Allergenex testing - unproven for rhinitis and all other indications; Allergy testing and desensitization for poison ivy, oak and sumac - unproven; Anti-Fc epsilon receptor antibodies testing - unproven; Anti-IgE receptor antibody testing - unproven; Atopy patch testing - unproven for diagnosis of food protein-induced enterocolitis syndrome (FPIES) and non-IgE gastrointestinal food allergy; Basophil activation test (BAT) - unproven; Body chemical analysis - unproven; Candidiasis test - unproven; Chlorinated pesticides (serum) - unproven; Chronic Urticaria Index testing - unproven; Clifford materials reactivity testing - unproven; Complement (total or components) - unproven for allergy (may be appropriate in autoimmune disorders, complement component deficiencies, hereditary angioedema, vasculitis); Complement antigen testing - unproven; Component-derived (component-resolved) diagnostic testing (CRD) - unproven for food allergy evaluation, except alpha-gal and Ara h 2 testing; C-reactive protein - unproven for allergy (may be appropriate in inflammatory diseases); Cytokine and cytokine receptor assay - unproven; Cytotoxic food testing (Bryans Test, ACT) - unproven; Cytotoxic testing (Bryans Test) - unproven for food sensitivity/allergy; Electrodermal acupuncture - unproven; Electrodermal testing - unproven for food sensitivity/allergy; ELISA/ACT - unproven; Eosinophil cationic protein (ECP) test - unproven; Food immune complex assays (FICA) - unproven; Food-specific IgG antibodies - unproven; Genetic testing for food allergy - unproven; IgG testing - unproven for food sensitivity/allergy; IgG4 testing - unproven for evaluation of allergy; Immune complex assay - unproven for allergy (may be appropriate in autoimmune disorders, systemic lupus erythematosus, vasculitis); Immune complex testing - unproven for food sensitivity/allergy; Infinite Allergy Labs' Food Allergy Sensitivity Test (FAST) panel - unproven; In-vitro metal allergy testing (lymphocyte transformation tests, LTT) - unproven / not medically necessary; In vitro histamine release testing (leukocyte histamine release test) - unproven; In vitro lymphocyte proliferation test - unproven; Leukocyte antibodies testing - unproven; Lymphocytes (B or T subsets) - unproven for allergy (may be appropriate for collagen vascular disease, immune deficiency syndromes, leukemia, lymphomas); Lymphocyte function assay - unproven; Lymphocyte or basophil phenotyping - unproven for food allergy; Mediator release test (MRT) - unproven; Muscle strength testing or measurement (kinesiology) after allergen ingestion - unproven; Ophthalmic mucous membrane tests / conjunctival challenge tests - unproven; Prausnitz-Kustner (P-K) testing / passive cutaneous transfer test - unproven; contraindicated due to risk of transmitting hepatitis or AIDS; Provocative nasal test (nasal provocation testing) - unproven; Provocation-neutralization testing (Rinkel Test), whether subcutaneous or sublingual - unproven; Pulse test (pulse response test, reaginic pulse test) - unproven; Rebuck skin window test - unproven; Routine percutaneous allergy testing after allergen immunotherapy - not medically necessary unless new symptoms, failure of improvement, or return of symptoms after the immunotherapy course; Serum immunoglobulin A (IgA) and immunoglobulin G (IgG) testing - unproven for allergy; Skin patch testing - not medically necessary for irritable bowel syndrome; Sublingual provocative neutralization testing and treatment with hormones - unproven; Testing for electromagnetic sensitivity syndrome/disorder (a.k.a. allergy to electricity, electro-sensitivity, electro-hypersensitivity) - unproven; Testing for food-specific IgE to identify food triggers of FPIES - unproven; Testing for multiple chemical sensitivity syndrome (a.k.a. idiopathic environmental intolerance / IEI, clinical ecological illness, environmental illness, chemical AIDS, total allergy syndrome, cerebral allergy, 20th century disease) - unproven; Tests of lymphocyte activation - unproven for food sensitivity/allergy; Venom blocking antibodies - unproven; VeriMAP Peanut DX - unproven; Volatile chemical panels (blood testing for chemicals) - unproven; Acupuncture - unproven for allergies; Allergoids (modification of allergens to reduce allergenicity) - unproven; Allergy immunotherapy for angioedema - unproven; Allergy immunotherapy for atopic dermatitis (except dust mite atopic dermatitis) - unproven; Allergy immunotherapy for chronic urticaria - unproven; Allergy immunotherapy for food allergy (except FDA-approved peanut OIT per CPB 0968) - unproven; Allergy immunotherapy for intrinsic (non-allergic) asthma - unproven; Allergy immunotherapy for migraine headaches - unproven; Allergy immunotherapy for non-allergic vasomotor rhinitis - unproven; Allergy immunotherapy for tree nut allergy - unproven; Autogenous urine immunization (autogenous urine therapy) - unproven; Autologous whole-blood or autologous serum acupoint injection - unproven for treatment of chronic urticaria; Bacterial immunotherapy - unproven; Chemical cautery of nasal mucosa - unproven for treatment of allergic rhinitis; Detoxification - unproven for allergies; Ecology units / environmental control units / environmental chemical avoidance - unproven for multiple chemical sensitivity syndrome; Enzyme potentiated desensitization (EPD) - unproven; Helminth Trichuris suis therapy - unproven for allergic rhinitis; Home administration of allergy immunotherapy - not medically necessary / not covered; Homeopathy - unproven for allergies; Intradermal grass pollen immunotherapy - unproven for treatment of allergic rhinitis / not covered; Intramuscular (IM) steroids - not medically necessary for treatment of acute sinusitis and allergic rhinitis; Intranasal immunotherapy - not medically necessary / not covered; Mechanical allergen particle barrier / inhalation filter, cream, nasal, topical (e.g., Alzair Allergy Blocker) - unproven; Neutralization therapy (desensitization neutralization therapy) - unproven; Neutralizing therapy of chemical and food extracts - unproven; Oral immunotherapy (OIT) for egg allergy and food allergy (except FDA-approved OIT for peanut allergy) - unproven; Oral nystatin - unproven for treatment of candidiasis hypersensitivity syndrome; Photo-inactivated extracts - unproven; Polymerized extracts - unproven; Poison ivy / poison oak extracts - unproven for immunotherapy in prevention of toxicodendron (Rhus) dermatitis; Probiotics - unproven for food allergy prevention or treatment; Quantitative bradykinin - unproven; Repository emulsion therapy - unproven; Rhino-phototherapy - unproven; Subcutaneous steroids - not medically necessary for treatment of allergic rhinitis; Sublingual drops / sublingual immunotherapy - unproven except Oralair, Grastek, and Ragwitek; Sublingual immunotherapy - not medically necessary for asthmatic children sensitized to house dust mite; Treatments for electromagnetic sensitivity syndrome/disorder - unproven; Ultra low dose enzyme activated immunotherapy (low dose allergens / LDA) - unproven; Routine allergy re-testing - not medically necessary; Performance of both percutaneous allergy tests and IgE RAST (blood) tests for the same allergens - not medically necessary; Repeated percutaneous allergy testing for monitoring response to immunotherapy - not medically necessary; Intradermal (intracutaneous) testing for food allergy diagnosis - not appropriate due to high false-positive rate and anaphylaxis risk; Skin endpoint titration (SET) used in place of skin testing - inappropriate. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.
Does Aetna require prior authorization for Allergy Testing and Immunotherapy?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source.
What does Aetna exclude for Allergy Testing and Immunotherapy?
Policy exclusions and limitations: ALCAT test (automated food allergy test) - experimental/investigational/unproven; Allergen-specific IgG (RAST/ELISA) testing - unproven for allergy evaluation; Allergenex testing - unproven for rhinitis and all other indications; Allergy testing and desensitization for poison ivy, oak and sumac - unproven; Anti-Fc epsilon receptor antibodies testing - unproven; Anti-IgE receptor antibody testing - unproven; Atopy patch testing - unproven for diagnosis of food protein-induced enterocolitis syndrome (FPIES) and non-IgE gastrointestinal food allergy; Basophil activation test (BAT) - unproven; Body chemical analysis - unproven; Candidiasis test - unproven; Chlorinated pesticides (serum) - unproven; Chronic Urticaria Index testing - unproven; Clifford materials reactivity testing - unproven; Complement (total or components) - unproven for allergy (may be appropriate in autoimmune disorders, complement component deficiencies, hereditary angioedema, vasculitis); Complement antigen testing - unproven; Component-derived (component-resolved) diagnostic testing (CRD) - unproven for food allergy evaluation, except alpha-gal and Ara h 2 testing; C-reactive protein - unproven for allergy (may be appropriate in inflammatory diseases); Cytokine and cytokine receptor assay - unproven; Cytotoxic food testing (Bryans Test, ACT) - unproven; Cytotoxic testing (Bryans Test) - unproven for food sensitivity/allergy; Electrodermal acupuncture - unproven; Electrodermal testing - unproven for food sensitivity/allergy; ELISA/ACT - unproven; Eosinophil cationic protein (ECP) test - unproven; Food immune complex assays (FICA) - unproven; Food-specific IgG antibodies - unproven; Genetic testing for food allergy - unproven; IgG testing - unproven for food sensitivity/allergy; IgG4 testing - unproven for evaluation of allergy; Immune complex assay - unproven for allergy (may be appropriate in autoimmune disorders, systemic lupus erythematosus, vasculitis); Immune complex testing - unproven for food sensitivity/allergy; Infinite Allergy Labs' Food Allergy Sensitivity Test (FAST) panel - unproven; In-vitro metal allergy testing (lymphocyte transformation tests, LTT) - unproven / not medically necessary; In vitro histamine release testing (leukocyte histamine release test) - unproven; In vitro lymphocyte proliferation test - unproven; Leukocyte antibodies testing - unproven; Lymphocytes (B or T subsets) - unproven for allergy (may be appropriate for collagen vascular disease, immune deficiency syndromes, leukemia, lymphomas); Lymphocyte function assay - unproven; Lymphocyte or basophil phenotyping - unproven for food allergy; Mediator release test (MRT) - unproven; Muscle strength testing or measurement (kinesiology) after allergen ingestion - unproven; Ophthalmic mucous membrane tests / conjunctival challenge tests - unproven; Prausnitz-Kustner (P-K) testing / passive cutaneous transfer test - unproven; contraindicated due to risk of transmitting hepatitis or AIDS; Provocative nasal test (nasal provocation testing) - unproven; Provocation-neutralization testing (Rinkel Test), whether subcutaneous or sublingual - unproven; Pulse test (pulse response test, reaginic pulse test) - unproven; Rebuck skin window test - unproven; Routine percutaneous allergy testing after allergen immunotherapy - not medically necessary unless new symptoms, failure of improvement, or return of symptoms after the immunotherapy course; Serum immunoglobulin A (IgA) and immunoglobulin G (IgG) testing - unproven for allergy; Skin patch testing - not medically necessary for irritable bowel syndrome; Sublingual provocative neutralization testing and treatment with hormones - unproven; Testing for electromagnetic sensitivity syndrome/disorder (a.k.a. allergy to electricity, electro-sensitivity, electro-hypersensitivity) - unproven; Testing for food-specific IgE to identify food triggers of FPIES - unproven; Testing for multiple chemical sensitivity syndrome (a.k.a. idiopathic environmental intolerance / IEI, clinical ecological illness, environmental illness, chemical AIDS, total allergy syndrome, cerebral allergy, 20th century disease) - unproven; Tests of lymphocyte activation - unproven for food sensitivity/allergy; Venom blocking antibodies - unproven; VeriMAP Peanut DX - unproven; Volatile chemical panels (blood testing for chemicals) - unproven; Acupuncture - unproven for allergies; Allergoids (modification of allergens to reduce allergenicity) - unproven; Allergy immunotherapy for angioedema - unproven; Allergy immunotherapy for atopic dermatitis (except dust mite atopic dermatitis) - unproven; Allergy immunotherapy for chronic urticaria - unproven; Allergy immunotherapy for food allergy (except FDA-approved peanut OIT per CPB 0968) - unproven; Allergy immunotherapy for intrinsic (non-allergic) asthma - unproven; Allergy immunotherapy for migraine headaches - unproven; Allergy immunotherapy for non-allergic vasomotor rhinitis - unproven; Allergy immunotherapy for tree nut allergy - unproven; Autogenous urine immunization (autogenous urine therapy) - unproven; Autologous whole-blood or autologous serum acupoint injection - unproven for treatment of chronic urticaria; Bacterial immunotherapy - unproven; Chemical cautery of nasal mucosa - unproven for treatment of allergic rhinitis; Detoxification - unproven for allergies; Ecology units / environmental control units / environmental chemical avoidance - unproven for multiple chemical sensitivity syndrome; Enzyme potentiated desensitization (EPD) - unproven; Helminth Trichuris suis therapy - unproven for allergic rhinitis; Home administration of allergy immunotherapy - not medically necessary / not covered; Homeopathy - unproven for allergies; Intradermal grass pollen immunotherapy - unproven for treatment of allergic rhinitis / not covered; Intramuscular (IM) steroids - not medically necessary for treatment of acute sinusitis and allergic rhinitis; Intranasal immunotherapy - not medically necessary / not covered; Mechanical allergen particle barrier / inhalation filter, cream, nasal, topical (e.g., Alzair Allergy Blocker) - unproven; Neutralization therapy (desensitization neutralization therapy) - unproven; Neutralizing therapy of chemical and food extracts - unproven; Oral immunotherapy (OIT) for egg allergy and food allergy (except FDA-approved OIT for peanut allergy) - unproven; Oral nystatin - unproven for treatment of candidiasis hypersensitivity syndrome; Photo-inactivated extracts - unproven; Polymerized extracts - unproven; Poison ivy / poison oak extracts - unproven for immunotherapy in prevention of toxicodendron (Rhus) dermatitis; Probiotics - unproven for food allergy prevention or treatment; Quantitative bradykinin - unproven; Repository emulsion therapy - unproven; Rhino-phototherapy - unproven; Subcutaneous steroids - not medically necessary for treatment of allergic rhinitis; Sublingual drops / sublingual immunotherapy - unproven except Oralair, Grastek, and Ragwitek; Sublingual immunotherapy - not medically necessary for asthmatic children sensitized to house dust mite; Treatments for electromagnetic sensitivity syndrome/disorder - unproven; Ultra low dose enzyme activated immunotherapy (low dose allergens / LDA) - unproven; Routine allergy re-testing - not medically necessary; Performance of both percutaneous allergy tests and IgE RAST (blood) tests for the same allergens - not medically necessary; Repeated percutaneous allergy testing for monitoring response to immunotherapy - not medically necessary; Intradermal (intracutaneous) testing for food allergy diagnosis - not appropriate due to high false-positive rate and anaphylaxis risk; Skin endpoint titration (SET) used in place of skin testing - inappropriate. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source

Aetna CPB 0038 — Allergy Testing and Immunotherapy

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0038 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.