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HSA Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

PPO 750 Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

PPO 1250 Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

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:

  • Foods
  • Hymenoptera venom (stinging insects)
  • Inhalants
  • Specific drugs (penicillins and macromolecular agents)

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:

  • Hymenoptera venom (stinging insects)
  • Inhalants

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:

  • Bronchial challenge test is being used to identify new allergens for which skin or blood testing has not been validated; or
  • Skin testing is unreliable.

Exercise Challenge Testing for exercise-induced bronchospasm.

Ingestion (Oral) Challenge Test for any of the following:

  • Food or other substances (i.e., metabisulfite); or
  • Drugs when all of the following are met:
    • History of allergy to a particular drug; and
    • There is no effective alternative drug; and
    • Treatment with that drug class is essential.

In Vitro IgE Antibody Tests (RAST, MAST, FAST, ELISA, ImmunoCAP) for:

  • Allergic broncho-pulmonary aspergillosis (ABPA) and certain parasitic diseases; or
  • Food allergy; or
  • Hymenoptera venom allergy (stinging insects); or
  • Inhalant allergy; or
  • Specific drugs.

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:

  • Allergic (extrinsic) asthma
  • Dust mite atopic dermatitis
  • Hymenoptera (bees, hornets, wasps, fire ants) sensitive individuals
  • Mold-induced allergic rhinitis
  • Perennial rhinitis
  • Seasonal allergic rhinitis or conjunctivitis when all of the following conditions are met:
    • Member has symptoms of allergic rhinitis and/or asthma after natural exposure to the allergen; or
    • Member has a life-threatening allergy to insect stings (bees, hornets, wasps and fire ants), and
    • Member has skin test and/or serologic evidence of IgE-mediated antibody to a potent extract of the allergen, and
    • Avoidance or pharmacologic therapy cannot control allergic symptoms or member has unacceptable side effects with pharmacologic therapy.

Other treatments considered medically necessary:

  • Rapid desensitization (a.k.a., rush, cluster or acute desensitization) for members with any of the following conditions:
    • IgE antibodies to a particular drug that cannot be treated effectively with alternative medications; or
    • Insect sting (e.g., wasps, hornets, bees, fire ants) hypersensitivity (hymenoptera); or
    • Members with moderate to severe allergic rhinitis who need treatment during or immediately before the season of the affecting allergy.
    Rapid desensitization is considered experimental and investigational for other indications.
  • Epinephrine kits to prevent anaphylactic shock for individuals who have had life-threatening reactions to insect stings, foods, drugs or other allergens or have severe asthma or if needed during immunotherapy.

    Epinephrine kits are considered experimental and investigational for other indications.

Routine allergy re-testing is not considered medically necessary.


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