BlueCross BlueShield of Tennessee Medical Policy Manual

Immunology

• Active Specific Immunotherapy: Melanoma Vaccine

• Adoptive Immunotherapy

• Autogenous Urine Immunization

• Bronchial Challenge Test

• Cidofovir

• Conjunctival Challenge Test

• Cytomegalovirus Immune Globulin Intravenous, Human (CMV-IVIG)

• Cytotoxic Food Tests

• Hepatitis B Immune Globulin

• Human Papillomavirus (HPV) Vaccine

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

• Infliximab - Injectable

• Interferons Alfa (Systemic)

• Intravenous Immune Globulin (IVIG) Therapy

• Late Lyme Disease, Treatment

• Leukocyte Histamine Release Test (LHRT)

• Lymphocytic Mitogen Response Assay for the Diagnosis of Vitamin, Mineral, and Antioxidant Functional Deficiencies

• Nasal Challenge Test

• Omalizumab

• Palivizumab

• Patch Test and Photo Patch Test

• Percutaneous Testing (Scratch, Prick, or Puncture)

• Poly-L-Lactic Acid Injectable Implant Device

• Posaconazole

• Positron Emission Tomography (PET) for Miscellaneous Applications

• Provocative and Neutralization Therapy for Food Allergies

• Provocative Tests for Food or Food Additives and Food Challenge Testing

• Repository Emulsion Therapy

• Rho (D) Immune Globulins

• Rotavirus Vaccine

• Serial Dilution Endpoint Titration and Intradermal Skin Test

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

• Sublingual Immunotherapy

• Total Serum IgE Concentration

• Urine-Based HIV-1 Testing System

• Zoster Vaccine, Live

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