BlueCross BlueShield of Tennessee Medical Policy Manual

Immunology

• Active Specific Immunotherapy: Melanoma Vaccine

• Adoptive Immunotherapy

• Canakinumab

• Complementary and Alternative Medicine

• Conjunctival Challenge Test

• 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

• Intravenous Immune Globulin (IVIG) Therapy

• 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

• 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

• Rh0(D) Immune Globulin

• Rotavirus Vaccine

• Sipuleucel-T

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

• Sublingual Immunotherapy

• Testing and Treatment for Lyme Disease

• Urine-Based HIV-1 Testing System

• Ustekinumab

• Zoster Vaccine, Live

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