No coverage for non-physician allergy services or associated expenses relating to an allergic condition, including installation of air filters, air purifiers or air ventilation system cleaning. MCHCP considers the specific allergy testing and treatment described below medically necessary.
Allergy testing and allergy immunotherapy are considered medically necessary for members with clinically significant allergic symptoms.
Epicutaneous (scratch, prick or puncture) and Intradermal (Intracutaneous) when IgE-mediated reactions occur to any of the following:
Skin or Serial Endpoint Titration (SET), also known as intradermal dilutional testing (IDT), for determining the starting dose for immunotherapy for members highly allergic to:
Skin Patch Testing for diagnosing contact allergic dermatitis.
Photo Patch Testing for diagnosing photo-allergy (e.g., photo-allergic contact dermatitis).
Photo Tests for evaluating photo-sensitivity disorders.
Bronchial Challenge Test for testing with methacholine, histamine or antigens in defining asthma or airway hyperactivity when either of the following conditions is met:
Exercise Challenge Testing for exercise-induced bronchospasm.
Ingestion (Oral) Challenge Test for any of the following:
In Vitro IgE Antibody Tests (RAST, MAST, FAST, ELISA, ImmunoCAP) for:
Total Serum IgE for diagnostic evaluation in members with known or suspected ABPA and or hyper IgE syndrome.
Lymphocyte transformation tests (lymphocyte mitogen response test, PHE stimulation test, lymphocyte antigen response assay) for evaluating persons with sensitivity to beryllium; for evaluation of persons suspected of having congenital or acquired immunodeficiency diseases affecting cell-mediated immunity, such as 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, and chronic mucocutaneous candidiasis; and, for evaluation of persons with thymoma and to predict allograft compatibility in the transplant setting.
Lymphocyte transformation tests are considered experimental and investigational for evaluation of persons with allergies or other hypersensitivities.
Allergy immunotherapy for the treatment of the following IgE-mediated allergies:
Other treatments considered medically necessary:
Routine allergy re-testing is not considered medically necessary.
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