Allergy and Hypersensitivity — CPB 0038 | AETNA Coverage Update

Aetna modified CPB 0038 covering allergy testing and hypersensitivity, effective December 18, 2025. Here's what billing teams need to know.

Aetna, a CVS Health company, updated Clinical Policy Bulletin CPB 0038 governing allergy and hypersensitivity coverage. This revision affects a broad set of CPT codes—including 95004, 95024, 95044, 95115–95126, 86003, and 94070, among many others—used by allergists, immunologists, pulmonologists, and dermatologists. If your practice bills Aetna for allergy testing or allergen immunotherapy, the updated medical necessity criteria and expanded non-covered designations deserve your attention before December 18, 2025.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Allergy and Hypersensitivity — CPB 0038
Policy Code	CPB 0038
Change Type	Modified
Effective Date	December 18, 2025
Impact Level	High
Specialties Affected	Allergy/Immunology, Pulmonology, Dermatology, ENT, Primary Care
Key Action	Audit your allergy testing charge capture against updated medical necessity criteria and non-covered code designations before December 18, 2025

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Aetna Allergy Testing Coverage Criteria and Medical Necessity Requirements 2025

The Aetna allergy coverage policy under CPB 0038 sets a three-part gate before any allergy testing qualifies as medically necessary. All three criteria must be met — not just one or two.

First, the member's symptoms must not be adequately controlled by empiric conservative therapy. Second, the testing must correlate specifically to the member's history, risk of exposure, and physical findings. Third, the test technique and allergens tested must have proven efficacy through peer-reviewed literature.

That third criterion is where a lot of claims run into trouble. "Proven efficacy in peer-reviewed literature" is how Aetna justifies its long list of non-covered and experimental designations. If a test doesn't clear that bar, it's out — regardless of what your ordering physician documents.

Epicutaneous and Intradermal Testing

For epicutaneous testing (CPT 95004) — scratch, prick, or puncture — Aetna covers IgE-mediated reactions to foods, hymenoptera venom, inhalants, and specific drugs (penicillins and macromolecular agents). Intradermal testing (CPT 95024) covers the same categories except food allergy.

Aetna is explicit: intradermal tests are not appropriate for food allergy diagnosis. The policy cites high false-positive rates and elevated anaphylaxis risk. Bill intradermal tests for food allergy and you're looking at a claim denial.

For inhalant allergy evaluation, up to 70 percutaneous tests followed by up to 40 intracutaneous tests are considered medically necessary. Intracutaneous tests are usually appropriate only when percutaneous tests come back negative. Document that sequence clearly in your records.

Skin Endpoint Titration (SET) / Intradermal Dilutional Testing

SET, billed as intradermal dilutional testing (CPT 95027), is covered only to determine the starting dose for immunotherapy in highly allergic members — specifically those with hymenoptera venom allergy or inhalant allergies. Up to 14 titration tests may be necessary. If any initial result is positive, up to 40 additional antigens or 80 IDT injections may be medically necessary.

The policy draws a hard line here: SET is not a substitute for standard skin testing. Using it in place of standard skin testing is explicitly inappropriate under this coverage policy. If your providers are substituting SET for routine skin testing, that's a denial waiting to happen.

Patch, Photo Patch, and Photo Testing

Skin patch testing (CPT 95044) is covered for diagnosing contact allergic dermatitis, with up to 80 units considered medically necessary. Photo patch testing (CPT 95052) covers photo-allergic contact dermatitis. Photo tests (CPT 95056) cover photo-sensitivity disorders.

These are fairly clean indications. The risk here is over-testing — exceeding the 80-unit limit on patch testing without documented necessity.

Bronchial and Exercise Challenge Testing

Bronchial challenge testing (CPT 95070, 94070) is medically necessary under two specific circumstances: when used to identify new allergens without validated skin or blood testing, or when skin testing is unreliable. Spirometry codes 94010 and 94060 are covered when criteria are met. Exercise challenge testing (CPT 94617) is covered for exercise-induced bronchospasm.

These tests sit at the intersection of allergy billing and pulmonary billing. If your pulmonology team also bills Aetna, loop them in on the updated criteria.

In Vitro IgE Testing

CPT 86003 (allergen-specific IgE, quantitative) is covered for up to 40 in vitro IgE antibody tests per the policy. In vitro testing (RAST, MAST, FAST, ELISA, ImmunoCAP — also reported with 83516, 83518, 83519, 83520) is appropriate when skin test-suppressive medications can't be stopped or when dermatographism or other skin conditions make skin testing unreliable. CPT 82785 (IgE total) is also covered when selection criteria are met.

Note: the source data for CPB 0038 provided to this summary was truncated. The full policy text may include additional covered indications for in vitro IgE testing. Verify the complete clinical criteria against the full CPB 0038 text or the PayerPolicy version diff before finalizing your documentation protocols.

Allergen Immunotherapy

Allergen immunotherapy codes (CPT 95115 through 95126 and beyond) are covered when criteria are met. Immunotherapy is a significant reimbursement line for allergy practices — and a common target for prior authorization requirements. Confirm prior auth requirements for your specific Aetna plan contracts before December 18, 2025. Plan-level variations exist, and not every Aetna product follows the same prior auth rules.

Ingestion Challenge Testing

Oral challenge testing (CPT 95076, 95079) is covered for food, other substances like metabisulfite, and drugs. Drug challenges require all three of the following: a history of allergy to the specific drug, no effective alternative drug, and that the drug class is essential for treatment. All three must be documented.

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Aetna Allergy Testing Exclusions and Non-Covered Indications

This section is where CPB 0038 gets dense — and where your denial risk is highest.

Aetna explicitly lists a set of allergy tests as not medically necessary, experimental, or investigational. These include tests grouped under basophil activation testing (BAT) and genetic testing for food allergy. The CPT codes flagged in that non-covered group include 82784, 82787, 84238, 84600, 86001, 86015, 86021, 86036, 86037, 86140, 86160, 86161, 86162, 86243, 86332, 86343, 86352, 86356, 86357, 86359, 86360, 86485, 86628, 88184, 88185, 88341, 88342, 88344, 88346, 95060, 95065, 95831, 95832, 95833, and 95834.

That's a long list. If your providers order any of these tests in the context of allergy workup, you need to flag them before billing. Several — like 86343 (leukocyte histamine release test) and flow cytometry codes 88184/88185 — appear regularly on allergy orders and generate denials when billed without understanding their non-covered status under this policy.

The basophil activation test (BAT) specifically is gaining interest clinically, but Aetna's position is that it lacks sufficient peer-reviewed evidence for routine use. Bill it anyway and you'll get denied. If your providers feel strongly, the path is prior auth with supporting literature — not just billing and hoping.

Genetic testing for food allergy falls in the same non-covered bucket. Aetna does not consider genetic testing a validated method for diagnosing food allergies under this coverage policy. Code 0605U (hereditary alpha tryptasemia, TPSAB1 gene copy number) is separately covered when criteria are met — but that's a specific hereditary condition, not general food allergy genetics.

Aetna groups manual muscle testing codes 95831–95834 in the non-covered category under this policy. The policy does not specify a rationale, but these codes are associated with allergy testing methods Aetna considers unproven.

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Coverage Indications at a Glance

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Aetna Allergy Billing Guidelines and Action Items 2025

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Allergy Testing Under CPB 0038

Note on ICD-10 codes: CPB 0038 includes 627 ICD-10-CM diagnosis codes. They are not fully reproduced in this summary. For the complete ICD-10 list, review the full policy text directly or use PayerPolicy's version diff tool to see the exact code set.

Covered CPT Codes (When Selection Criteria Are Met)

Not Covered / Experimental Codes — Basophil Activation Test (BAT) and Genetic Testing for Food Allergy

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