Medical Policy

MP 2.04.500 Diagnostic Tests for Allergic and Immune Deficiency Diseases of Uncertain Efficacy

Last Review: 05/27/2021 Related Policies Effective Date: 05/27/2021 9.01.502 Experimental / Investigational Services Section: Medicine

DISCLAIMER/INSTRUCTIONS FOR USE Medical policy provides general guidance for applying Blue Cross of Idaho benefit plans (for purposes of medical policy, the terms “benefit plan” and “member contract” are used interchangeably). Coverage decisions must reference the member specific benefit plan document. The terms of the member specific benefit plan document may be different than the standard benefit plan upon which this medical policy is based. If there is a conflict between a member specific benefit plan and the Blue Cross of Idaho’s standard benefit plan, the member specific benefit plan supersedes this medical policy. Any person applying this medical policy must identify member eligibility, the member specific benefit plan, and any related policies or guidelines prior to applying this medical policy, including the existence of any state or federal guidance that may be specific to a line of business. Blue Cross of Idaho medical policies are designed for informational purposes only and are not an authorization, explanation of benefits or a contract. Receipt of benefits is subject to satisfaction of all terms and conditions of the member specific benefit plan coverage. Blue Cross of Idaho reserves the sole discretionary right to modify all its policies and guidelines at any time. This medical policy does not constitute medical advice. POLICY The following tests are considered investigational, because they have not been shown to improve net health outcomes: 1. Antigen leukocyte cellular (ALCAT) automated food test 2. Applied kinesiology allergy test 3. Conjunctival challenge test (ophthalmic mucous membrane test) 4. Cytotoxic food tests 5. Electrodermal testing (also known as electro-acupuncture) 6. Hair analysis 7. IgG/IgG4 specific antibody test and food tests 8. Iridology 9. Leukocyte histamine release test (LHRT) 10. Nasal challenge test 11. Provocation-neutralization food or food additive allergy test POLICY GUIDELINES The following allergy tests are considered clinically useful for allergy confirmation by the American Academy of Allergy, Asthma, and (AAAI) and the American College of Allergy, Asthma and Immunology (ACAAI) in the diagnosis and management of the allergic patient 1: • Bronchial challenge test • Double-blind food challenge test • Intradermal skin testing

MP 2.04.500 Unproven and Inappropriate Diagnostic Tests for Allergic and Immune Deficiency Diseases

• • Percutaneous skin tests such as the scratch, prick, or puncture tests • Photo patch test • Specific IgE in vitro tests such as Radioallergosorbent Test (RAST), Multiple Radioallergosorbent Tests (MAST), Fluorescent Allergosorbent Test (FAST), Enzyme-linked Immunosorbent Assay (ELISA), and the ImmunoCAP IgE test • Total serum IgE concentration This policy addresses only allergy tests which are unproven or inappropriate based upon the scientific literature. BENEFIT APPLICATION BlueCard/National Account Issues State or federal mandates (e.g., Federal Employee Program) may dictate that certain U.S. Food and Drug Administration‒approved devices, drugs, or biologics may not be considered investigational, and thus these devices may be assessed only by their medical necessity. Benefit Exceptions This policy may not apply to all lines of business such as the Federal Employee Program, Medicare Supplement, Medicare Advantage, Medicaid, and certain self-insured groups. BACKGROUND Allergy Tests of Uncertain Efficacy This policy addresses only allergy tests of uncertain efficacy and those used primarily in research settings. Tests which may be considered useful in the clinical setting, as noted above, are not addressed in this policy. Antigen Leukocyte Cellular Antibody (ALCAT) Automated Food Test The ALCAT automated food test measures whole blood leukocytes by a proprietary process that identifies which cause an increase in leukocyte activity. An electronic counter measures the change in number and size of white blood cells which have been incubated with purified food or mold extracts. A histogram is produced based on cell count and cell size. Individually processed test samples are compared with a 'Master Control' graph. Scores are generated by relating these effective volumetric changes in white blood cells to the control curve. Applied Kinesiology (Or Muscle Strength Test) Muscle strength in the extremities is measured before and after a person is exposed to an allergen. Strength in the opposing arm is measured as a person holds a container of allergen extract in the opposite hand or ingests an allergen. A decrease in strength indicates the presence of disease and various nutritional supplements may be recommended. Cytotoxic Food Tests This test involves the response of especially collected white blood cells to the presence of food extracts to which the patient is allergic. A technician observes the unstained cells for changes in shape and appearance of the leukocytes. Swelling, vacuolation, crenation, or other cytotoxic changes in cell morphology are taken as evidence of allergy to the food. Electrodermal Testing (Also Known as Electro-Acupuncture)

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MP 2.04.500 Unproven and Inappropriate Diagnostic Tests for Allergic and Immune Deficiency Diseases

This test measures changes in skin resistance while a person is exposed to an allergen; either food or inhalant using an instrument that measures the electrical resistance of the skin. A drop in the resistance of the skin is believed to indicate the presence of allergy. Hair Analysis Hair is analyzed for the presence (or lack) of various minerals and toxins. Findings are correlated to nutritional deficiencies or disease. Recommendations for diet and supplements are provided based on the analysis. Iridology According to the AAAI, iridology attempts to relate the anatomical features in the iris to various systemic diseases. Igg/Igg4 Antibody Test and Food Specific Igg/Igg4 Tests There are four subclasses of immunoglobulin G. Selective deficiencies in one or more of the four IgG subclasses are seen in some patients with repeated infections. Measurements of IgG and specifically IgG4 have been used in research settings as diagnostic and prognostic tests to determine response to allergy treatments. Provocative-Neutralization Tests for Food (or Food Additive Allergy Test) This procedure is performed by injecting (intradermal or subcutaneous), or placing under the tongue (sublingual), dilute extracts of the suspected food or inhalant allergen and observing the patient’s response or reaction. A symptomatic response indicates an allergy to that food or inhalant, and the reaction can be neutralized by application of a similar extract of a lesser dilution. Allergy Tests in The Research Setting The following tests are primarily used in the research setting: Conjunctival Challenge Test With conjunctival testing, an allergenic extract is placed into the conjunctival sac of the eye followed by observation for redness, itchiness, tearing of the eye, and other similar symptoms. According to the AAAI, these tests are often used in research protocols that require an objective standard for evaluating clinical sensitivity to an allergen. Leukocyte Histamine Release Test (LHRT) In this testing, leukocytes from the serum of an allergic individual are observed for histamine release in the presence of an antigen. The commercial availability of simplified and automated methods of laboratory analysis has renewed interest in the clinical applications of LHRT in the evaluation of food, inhalant, and drug . The AAAI guidelines for this test indicate it is primarily used in a research setting. Nasal Challenge Test This test provides precise measurements of changes in nasal airway resistance along with observations such as number of sneezes and measurement of inflammatory mediators in the nasal secretions after exposure to an allergen. The more commonly known "sniff test," uses a visual assessment of mucosal swelling and rhinorrhea after a small amount of dry pollen is inhaled. RATIONALE Effectiveness

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MP 2.04.500 Unproven and Inappropriate Diagnostic Tests for Allergic and Immune Deficiency Diseases

The following tests have no randomized, controlled clinical trials documenting outcomes and impact on treatment decisions and/or results from clinical trials are inconclusive or contradictory: 1-3, 11-14 • Antigen leukocyte cellular antibody (ALCAT) test • Applied kinesiology • Cytotoxic tests • Electrodermal testing • Hair analysis • IgG and IgG4 allergen specific antibody or food test • Iridology • Provocation-neutralization ESSENTIAL HEALTH BENEFITS The Affordable Care Act (ACA) requires fully insured non-grandfathered individual and small group benefit plans to provide coverage for ten categories of Essential Health Benefits (“EHBs”), whether the benefit plans are offered through an Exchange or not. States can define EHBs for their respective state. States vary on how they define the term small group. In Idaho, a small group employer is defined as an employer with at least two but no more than fifty eligible employees on the first day of the plan or contract year, the majority of whom are employed in Idaho. Large group employers, whether they are self-funded or fully insured, are not required to offer EHBs, but may voluntarily offer them. The ACA requires any benefit plan offering EHBs to remove all dollar limits for EHBs. REFERENCES 1. Wuthrich B, Unproven techniques in allergy diagnosis, J Investig Allergol Clinic Immunol 2005;15:86- 90 cited in American Academy of Allergy and Immunology Program Directors’ Core Curriculum Outline 2008 2. Bernstein IL, Li JT, Bernstein DI et al. Allergy Diagnostic Testing: An Updated Practice Parameter Ann Allergy Asthma Immunol 2008;100: S1-148 3. Griese M, Kusenbach G, Reinhardt D. Histamine release test in comparison to standard tests in diagnosis of childhood allergic asthma. Ann Allergy 1990;65(1):46-51 4. Skov PS, Mosbech M, Norn S et al. Sensitive glass microfibre-based histamine analysis for allergy testing in washed blood cells. Results compared with conventional leukocyte histamine release assay. Allergy 1985;40(3):213-8 5. Ostergaard PA, Ebbensen F, Nolte H et al. Basophil histamine release in the diagnosis of house dust mite and dander allergy of asthmatic children. Comparison between prick test, RAST, basophil histamine release and bronchial provocation. Allergy 1990;45(3):231-5 6. Kleine-Tebbe J, Werfel S, Roedsgaard D et al. Comparison of fiberglass-based histamine assay with a conventional automated fluorometric histamine assay, case history, skin prick test, and specific serum IgE in patients with milk and egg allergic reactions. Allergy 1993;48(1):49-53 7. Kleine-Tebbe J, Galleani M, Jeep S et al. Basophil histamine release in patients with birch pollen hypersensitivity with and without allergic symptoms to fruits. Allergy 1992;47(6):618-23 8. Paris-Kohler A, Demoly P, Persi L et al. In vitro diagnosis of cypress pollen allergy by using cytofluorometric analysis of basophils (Bastotest). J Allergy Clin Immunol 2000;105(2 pt 1):339-45 9. Nolte H, Storm K, Schiotz PO. Diagnostic value of a glass fibre-based histamine analysis for allergy testing in children. Allergy 1990;45(3):213-23 10. Noh G, Ahn H-S, Cho N-Y et al. The clinical significance of food specific IgE/IgG4 in food specific atopic . Pediatr Allergy Immunol 2007;18:63-70

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MP 2.04.500 Unproven and Inappropriate Diagnostic Tests for Allergic and Immune Deficiency Diseases

11. Aberer W, Hawranek T, Reider N et al. and G antibody profiles to grass pollen allergens during a short course of sublingual immunotherapy. J Investig Allergol Clin Immunol 2007;17(3):131-6 12. Huang S-W. Follow-up of children with and cough associated with milk allergy. Pediatr Allergy Immunol 2007;18:81-5 13. Chapman JA, Bernstein IL, Lee RE et al. : a practice parameter. Annals of Allergy, Asthma, & Immunol 2006;96:S1-268 14. Miadonna A, Leggieri E, Tedeschi A, et al. Clinical significance of specific IgE determination on nasal secretion. Clin Allergy 1983;13(2):155–164 CODES

Codes Number Description CPT 86001 Allergen specific IgG quantitative or semiquantitative; each allergen 86003 Allergen specific IgE; quantitative or semiquantitative, each allergen 86005 Allergen specific IgE; qualitative, multiallergen screen (dipstick, paddle, or disk) 86343 Leukocyte Histamine Release Test (LHRT) 86486 Skin test; unlisted antigen, each 86807 Serum screening for cytotoxic percent reactive antibody (PRA); standard method 86808 Serum screening for cytotoxic percent reactive antibody (PRA); quick method 95060 Ophthalmic mucous membrane tests 95065 Direct nasal mucous membrane test 95076 Ingestion challenge test (sequential and incremental ingestion of test items, e.g., food, drug or other substance); initial 120 minutes of testing 95079 Ingestion challenge test (sequential and incremental ingestion of test items, e.g., food, drug or other substance); each additional 60 minutes of testing (List separately in addition to code for primary procedure) 95199 Unlisted allergy/clinical immunologic service or procedure 96902 Microscopic examination of hairs plucked or clipped by the examiner (excluding collection by patient) to determine telogen and anagen counts, or structural hair shaft abnormality 97813 Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient 97814 Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure) 99199 Unlisted special service, procedure or report HCPCS P2031 Hair analysis (excluding arsenic)

POLICY HISTORY Date Action Reason 03/19/14 Replace Policy renumbered from 2.04.97 to 2.04.300. policy- update only 04/07/16 Replace policy Blue Cross of Idaho annual review; no change to policy statement. 04/25/17 Replace policy Blue Cross of Idaho annual review; no change to policy statement. 04/30/18 Replace policy Blue Cross of Idaho annual review; no change to policy statement. Medical policy renumbered from 2.04.300 to 2.04.500. Added codes: P2031, 82784, 95060, 95065, 95199, 97813, 97814 and 99199. Title changed from “Unproven and Inappropriate Diagnostic Tests for Allergic and Immune Deficiency Diseases” to “Diagnostic Tests for Allergic and

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MP 2.04.500 Unproven and Inappropriate Diagnostic Tests for Allergic and Immune Deficiency Diseases

Immune Deficiency Diseases of Uncertain Efficacy.” 04/18/19 Replace policy Blue Cross of Idaho adopted changes as noted, effective 07/15/2019. Removed Prausnitz Kustner and Rebuck Skin Window tests as they are no longer in use. Removed CPT 83516. 04/23/20 Replace policy Blue Cross of Idaho annual review; no change to policy statement. 06/25/20 Coding update Removed 82784 05/27/21 Replace policy Blue Cross of Idaho annual review; no change to policy statement.

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