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Allergy Testing Therapy Policy Updates

Thank you for your continued partnership with Centene/WellCare Health Plans of New Jersey. As you know, we continually review and update our payment and utilization policies to ensure that they are designed to comply with industry standards while delivering the best patient experience to our members.

We are writing today to inform providers that there will be a change to the application of the rules governing the provision of Allergy Testing and Therapy to Medicaid and NJ FamilyCare beneficiaries. Effective September 1, 2022, payment of Allergy Testing and Therapy CPT codes billed without the required supporting diagnosis codes will be denied based on medical necessity criteria.

Summary of Policy
Policy Number Policy Name Policy Description Lines of Business
CP.MP.100 Allergy Testing and Therapy Medical necessity guidelines for allergy testing and therapy Medicaid

In accordance with this policy, CPT codes 86332, 86343, 86485, 86628, 95060, 95065, 0165U, 0178U will be denied since they are not considered medically necessary. In addition, the CPT codes listed in the table below will be denied if not billed with the specified ICD-10 codes in the first four positions.

Denied CPT If not billed with one of the following ICD-10 Codes in one of the first four positions
86003, 86005, 86008, 95004, 95017, 95018, 95024, 95027, 95028 B44.81, H10.01* – H10.45, J30.1 – J30.9, J30.0, J31.0, J45.2* – J45.998, L20.84, L20.89, L20.9, L23.0 – L23.9*, L25.1 – L25.9, L27.0 – L27.9, L50.0, L50.1, L50.6, L50.8, L50.9, R06.2, T36.0X5A – T50.995S, T63.001* – T63.94*, T78.00X*– T78.1XXS, T78.49XA – T78.49XS, T80.52XA – T80.52XS, T88.6XXA – T88.6XXS, Z91.010 – Z91.018
95044 L20.84, L20.89, L20.9, L23.0 – L23.9, L50.0, L50.1, L50.6, L50.8, L50.9
95076, 95079 L56.1, L56.2, L56.3, L27.2, T36.0X5A – T50.995S, T78.00X* – T78.1XXS, Z88.0 – Z88.9, Z91.010 – Z91.018
95115, 95117,95144, 95145, 95146,95147, 95148, 95149,95165, 95170, 95199 H10.01* – H10.45, J30.1 – J30.9, J31.0, J45.20 – J45.998, L20.84, L20.89, L20.9, L23.0 – L23.9*, L25.1 – L25.9, L27.0 – L27.9, L50.0, L50.6, T36.0X5A – T50.995S, T63.001* – T63.94*, T78.49XA – T78.49XS, T80.52XA – T80.52XS, T88.6XXA – T88.6XXS, Z88.0 – Z88.9, Z91.030 – Z91.038
95180 T36.0X5A – T50.995S, Z91.030 – Z91.038

We thank you for your commitment to the care and wellbeing of our members and to the communities we serve.  Should you have any questions or concerns about this notification, please contact us at Provider Services (888) 453-2534. Policies are posted on our website at https://www.wellcarenewjersey.com/

Sincerely,

WellCare Health Plans of New Jersey