Allergies: when insurers say no, reviewers often say yes

Where the denial was overturned

The patient is a five-year-old male with a history of migraines, headaches, asthma, and allergies. Acupuncture has been recommended for treatment of these conditions. The Health Plan has denied this request on the basis acupuncture is not medically necessary for treatment of the patient’s condition.According to the California Department of Consumer Affairs, Acupuncture Board, the National Institutes of Health, and the World Health Organization, acupuncture is an acceptable and appropriate treatment for this patient’s condition. Acupuncture is commonly utilized to treat allergies/asthma, migraine headache, rhinitis, and sinusitis. There are controlled trials demonstrating acupuncture is an effective treatment for allergic rhinitis.

A 20-old female has requested allergy shots for treatment of her allergies. Findings: The physician reviewer found that based on review of the available records, this patient presents with moderate to severe allergic symptoms. Diagnostic testing including skin tests have been positive. As is the case for patients who are college students, injections must be given at a provider’s office at some distance from the student’s home during the school year. This patient’s records demonstrate the medical necessity for allergy injections. For these reasons, the patient’s request for allergy shots provided from the dates at issue and forward are medically necessary for management of her medical condition.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Leukocyte Histamine Release test provided on 11/10/17. The Health Plan has denied this request as investigational for evaluation of the enrollee’s possible allergies. Findings: There are insufficient medical notes provided to support the reasoning behind the test for leukocyte histamine release and whether it would be more beneficial in the evaluation and treatment of the patient than standard tests. While the release of histamine from leukocytes upon exposure to an allergen is a valid test for detection of specific IgE to the allergen used in the test, this test is not normally used clinically. It has been used traditionally as a research tool. Quality control studies have shown variability in the measurement of histamine results.

Nature of Statutory Criteria/Case Summary: An enrollee has requested IgG food sensitivity testing (CPT code 86001) for treatment of her allergies and fatigue. Three physician reviewers found that in this case, the patient underwent IgG food testing for possible food allergy and allergic rhinitis. The medical records submitted for review do not demonstrate a diagnosis consistent with a food allergy. The current National Institutes of Health National Institute of Allergy and Infectious Disease expert panel states that IgG food testing is not validated. Moreover, the Joint Task Force on Practice Parameters for the Allergy and Immunology also state that IgG food testing is not validated. As such, the IgG food testing is not the standard of care and was not likely to be more beneficial for evaluation of the patient’s medical condition than any available standard therapy.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for allergies was denied, the published record says the denial is worth fighting.