BlueCross BlueShield of Tennessee Medical Policy Manual

General Policy for Allergy Testing and Treatment

PURPOSE

To establish a basis for determining medical necessity of testing and treatment for allergic individuals.

DESCRIPTION

Allergy or hypersensitivity disorders may be manifested by generalized systemic reactions as well as localized reactions in any organ system of the body. The reactions may be acute, subacute or chronic, immediate or delayed, and may be caused by numerous offending agents, (e.g., pollen, molds, dust, mites, animal dander, stinging insect venoms, foods and drugs).

The optimum management of the allergic individual should include a careful history and physical examination and may include confirming the cause of allergic reaction by information from some of the testing methods listed below. Once the agent is identified, treatment is provided by avoidance, medication or immunotherapy.

Immunotherapy involves regular injections of an offending allergen over a period of months, with the goal of reducing symptoms. It begins with low doses to prevent untoward reactions, with gradually increasing doses injected once or twice a week as immunity to the antigen develops. After the maintenance dose is achieved, the interval between injections may range between two and six weeks. Immunotherapy may be administered continuously for several years.

POLICY

• BlueCross BlueShield of Tennessee recognizes the need for consistency in the determination of medical appropriateness for testing and treatment of allergies.

• Services will be considered medically appropriate only if they have met BlueCross BlueShield of Tennessee's technology evaluation criteria.

DIAGNOSTICS:

• Bronchial Challenge Test

• Complementary and Alternative Medicine

• Conjunctival Challenge Test

• Cytotoxic Food Tests

• In Vitro Particle Size Measurement for Screening Hypersensitivity Reactions to Foods and Chemicals

• Leukocyte Histamine Release Test (LHRT)

• Nasal Challenge Test

• Patch Test and Photo Patch Test

• Percutaneous Testing (Scratch, Prick, or Puncture)

• Provocative Tests for Food or Food Additives and Double Blind Food Challenge Test

• Serial Dilution Endpoint Titration and Intradermal Skin Test

• Specific IgE In Vitro Tests (RAST, MAST & FAST)

• Total Serum IgE Concentration Test

THERAPEUTICS:

• Acupuncture

• Autogenous Urine Immunization Therapy

• Provocative and Neutralization Therapy

• Repository Emulsion Therapy

• Sublingual Immunotherapy

ADDITIONAL INFORMATION

Injection vials of airborne and/or insect venom allergens should be prepared for the specific individual.

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

This document has been classified as public information.