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Allergy Testing denials: what the review data shows
Independent reviewers have decided 60 published cases where an insurer denied Allergy Testing — and they overturned the insurer 10% of the time. A denial for Allergy Testing is a starting position, not a final answer.
Published decisions
60
2001–2026
Overturned
10%
6 denials reversed
Conditions behind allergy testing denials
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Allergy | 23 | 0% |
| Resp Allergies | 3 | 0% |
| Asthma | 3 | 33.3% |
What the insurer actually argued
Denials fall into different categories, and they don’t succeed equally — so the reason on your letter changes how you should answer it.
| Reason given | Decisions | Overturned |
|---|---|---|
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 52 | 5.8% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 8 | 37.5% |
Typical time to a decision
21 days
Most land between 19 and 22 days
Recent direction
Falling
10% → 0% overturned, last three years
What the reviewers wrote
Excerpts from the independent reviewers’ published findings — the actual reasoning, quoted, not summarised.
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested allergy testing for evaluation of her medical condition. Findings: The physician reviewer found that the medical records fail to indicate any diagnosis consistent with a food allergy. The current National Institutes of Health National Institute of Allergy and Infectious Disease and the Joint Task Force on Practice Parameters for the Allergy and Immunology also state that IgG food testing is not validated. As such, IgG food testing is not the standard of care and is not medically necessary for evaluation of the patient’s medical condition. However, IgE testing may be helpful in treating this patient. About 50% of children and 35% of adults are sensitive to food or aeroallergens (Schafer).
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a breathing test. While the measurement of fractional exhaled nitric oxide (FENO) is not utilized by itself in the evaluation and management of asthma, it has been demonstrated to be of value in conjunction with clinical parameters. Its use is associated with significantly lower asthma exacerbation rates compared with asthma managed using clinical parameters alone. Further, a recently published review of the literature found that algorithms that include FENO measurements can help in monitoring response to anti-inflammatory, or long-term control medications, including dose titration, weaning, and treatment adherence. In this case, the patient has experienced side effects from various therapies.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an allergy skin test. Seidman and colleagues explain that allergic rhinitis is one of the most common disease affecting adults. Clinical practice guidelines report that a diagnosis of allergic rhinitis begins with a directed history and physical examination particularly noting pattern, chronicity, and triggers of symptoms. In this case, the patient has symptoms of intermittent cough, shortness of breath, scratchy throat, and postnasal drip. The records document prior treatment with allergy shots directed by a prior positive skin test, and allergies to tree pollen, weed pollen, dust, and dog dander. The patient had been off all medications since completing allergy shots in 2015.
Nature of Statutory Criteria/Case Summary: Allergen-specific IgG4 testing has not been demonstrated in randomized controlled clinical trials to be effective for routine clinical care and is not recommended for the evaluation of IgE-mediated food allergies per expert panel guidelines due to lack of evidence. Also noted in the 2014 Joint Task Force Updated Food Allergy Practice Parameters, “allergen-specific IgG measurement…should not be used for the evaluation of food allergy”. Similarly, allergen-specific IgG testing is not included in recommendations for diagnosis of non-IgE mediated immunologic adverse reactions to foods.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
How to use this in your appeal
These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Allergy Testingwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY
Not legal or medical advice. Coverage Rights is a self-help tool that helps you prepare your own appeal. For advice about your specific situation, talk to a licensed attorney or your doctor.