Allergy and Hypersensitivity (CPB 0038, reviewed 2026-03-10)

By March 10, 2026: Billing team must implement the following compliance measures: (1) Update billing system edits to enforce maximum test limits (70 percutaneous + 40 intradermal for inhalant testing; 40 in vitro tests for inhalant screening; 12 for food/other; up to 80 patch tests; up to 14 SET titration tests); (2) Configure system to DENY claims when BOTH percutaneous allergy tests AND IgE RAST tests are billed for identical allergens (not medically necessary per policy); (3) Require documentation in claims showing symptoms inadequately controlled by conservative therapy before approving allergy testing; (4) Add verification step that testing correlates to member's history, exposure risk, and physical findings; (5) Deny routine allergy re-testing unless new sensitivities emerge during/after immunotherapy or immunotherapy has failed; (6) Restrict repeated percutaneous testing to monitor immunotherapy response (not covered); (7) Ensure immunotherapy claims include documentation of severe IgE-dependent symptoms AND either skin/serologic evidence of IgE antibodies OR life-threatening insect sting allergy or allergen management failure; (8) Deny rapid desensitization claims except for drug allergies without alternatives, insect sting hypersensitivity, or moderate-severe rhinitis during allergy season when other treatments failed; (9) Route all claims for Ara h 2 testing and alpha-gal allergy testing only when specific clinical triggers documented (urticaria, angioedema, anaphylaxis, GI symptoms with syncope for alpha-gal; suspected peanut allergy for Ara h 2); (10) Providers must attach clinical documentation showing medical necessity criteria met; (11) Front desk staff should update encounter forms to include checkboxes for conservative therapy failure and documented IgE-mediated symptoms. Failure to implement these edits will result in high claim denial rates and member complaints.