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TRICARE Policy Manual 6010.60-M, April 1, 2015
Medicine
Chapter 7
Section 14.1
Allergy Testing And Treatment
Issue Date:  April 19, 1983
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  
1.0  CPT PROCEDURE CODE RANGEs
95004 - 95010, 95015 - 95199
2.0  DESCRIPTION
The testing and treatment of conditions related to allergies.
3.0  POLICY
Services and supplies required in the diagnosis and treatment of allergies are covered.
4.0  EXCLUSIONS
4.1  Unproven allergy testing. The following are examples of unproven allergy testing. This list is NOT intended to be all-inclusive:
•  In vitro histamine release.
•  Provocative and neutralization testing for food, environmental chemicals, inhalant allergens, and endogenous hormones.
•  Sublingual testing.
•  Cytotoxic leukocyte test for food and inhalant allergies.
•  Rebuck skin window test.
•  Passive transfer (Prausnitz-Kustner) test.
•  Serial skin-test end point titration for routine testing.
•  Kinesiology testing. This test involves muscle strength measurements after food ingestion or sublingual application of food extracts.
•  Reaginic Pulse test. This test measures the increase of pulse rates after ingestion of a suspected allergic food substance.
•  Enzyme-Linked Immunoabsorbent Assay (ELISA).
•  Electrodermal diagnosis.
•  Chemical analysis of body tissue.
•  Recall skin tests.
•  In vitro lymphocyte proliferation.
•  Food challenge testing performed in connection with clinical ecology programs.
•  Nitric oxide expired gas determination (Current Procedural Terminology (CPT) procedure code 95012) for asthma is unproven.
4.2  Unproven allergy treatment. The following are examples of unproven allergy treatment. This list is NOT intended to be all-inclusive:
•  Sublingual antigen therapy/Oral Immunotherapy (OIT).
•  Sublingual neutralization therapy for food and inhalant allergy.
•  Urine autoinjection (autogenous urine immunization).
•  Intracutaneous (intradermal) and subcutaneous neutralization therapy for food allergies.
•  Immunotherapy involving any injection of a food antigen.
•  Chemical exposure avoidance, special diet therapy, drug therapy and neutralization therapy for environmental allergies.
•  Total serum IgE concentration in cord blood.
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