5160-4-19. Allergy services

(A) Purpose. This rule addresses payment for the professional administration and evaluation of allergy sensitivity test procedures, which can be divided into three categories: allergy testing, ingestion challenge testing, and allergen immunotherapy. Payment for related laboratory tests is addressed in Chapter 5160-11 of the Administrative Code.

(B) Coverage.

(1) Allergy testing.

(a) There must be a reasonable probability, documented in the individual's medical file, that the individual was exposed to the antigen being used for the test.

(b) The unit of service is the test. Payment may be made only for the fewest number of tests necessary to reach a diagnosis.

(c) Payment includes all associated professional services. No payment is made for evaluation and management unless a separately identifiable service is performed.

(d) A qualitative multiallergen screen for allergen-specific immunoglobulin E (IgE) is not considered to be medically necessary.

(2) Ingestion challenge testing.

(a) The unit of service is the encounter. Payment may be made only once per visit regardless of the number of items tested.

(b) Payment includes the evaluation of the individual's response to the test items.

(3) Allergen immunotherapy.

(a) Payment includes all associated professional services. No payment is made for evaluation and management unless a separately identifiable service is performed.

(b) Payment for the antigen is made separately. No payment will be made for a service that includes administration (injection) as well as the antigen and its preparation.

(c) The unit of service is the dose-per-vial.

(d) Separate payment for the preparation of a single-dose vial of allergen antigen may be made only if the provider prepares the antigen for injection by another entity.

(e) The date of service is the date on which the first dose is administered or the date on which the vial is dispensed for future use.

(f) Immunotherapy is not considered to be medically necessary for the following antigens: newsprint, tobacco smoke, orris root, phenol, formalin, alcohol, sugar, yeast, grain mill dust, goldenrod, pyrethrum, marigold, soybean dust, honeysuckle, wool, fiberglass, green tea, and chalk.

Replaces: 5160-4-19

Effective: 4/1/2016
Five Year Review (FYR) Dates: 04/01/2021
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 09/01/1989, 04/01/1992 (Emer), 07/01/1992, 04/01/1993, 12/30/1993 (Emer), 03/03/1994, 12/30/1994 (Emer), 03/20/1995, 01/01/2001, 09/01/2005, 08/02/2011, 12/31/2012 (Emer), 03/28/2013