Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

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. The patient reported that an exacerbation in symptoms in December 2021 was not responsive to loratadine but responded to Halls menthol cough drops and a Vicks inhaler. In this case, the documentation only noted a lack of triggers including no new pets, carpeting, exacerbation at work, or even outdoors predilection. The  patient was seen as a telemedicine allergy consultation without an examination. Penagos and Durham note that allergen immunotherapy is effective for the treatment of allergic rhinitis and that data strongly support recommendations in international guidelines that both sublingual and subcutaneous immunotherapy should be continued for a minimum of three years to achieve disease modification and long-term tolerance. In this case, the records document that the patient was able to stop allergy medications between 2015 and 2021.  Lai and colleagues note that the differential diagnosis of cough with a scratchy throat includes not just allergic rhinitis, but all forms of rhinitis, such as nonallergic rhinitis, bacterial sinusitis, allergic fungal sinusitis, rhinitis due to anatomic sinonasal abnormalities, rhinitis due to physical or chemical irritants, occupational rhinitis, and rhinitis medicamentosa. Other causes of cough may include asthma and reactive airways, chronic bronchitis or chronic obstructive pulmonary disease (COPD), bronchiectasis, viral infections, pertussis, and gastroesophageal reflux. Sylvester and colleagues report that treatment for chronic cough may include a prolonged trial of intranasal steroids, anti-reflux regimens, or decongestants. In this case, the records did not note that intranasal steroids, which may also be effective in both nonallergic and allergenic rhinitis, were prescribed. The patient reported that an exacerbation in symptoms in December 2021 responded to Halls menthol cough drops and Vicks inhaler, medications for nonallergic post nasal drip or viral infections, and not to loratadine, suggesting that his condition was nonallergic.  The Health Quality Ontario notes that the accuracy of skin testing for allergic rhinitis is still debated and the diagnostic accuracy of intradermal testing is not established. Rather than repeat skin testing, better diagnostic modalities for the diagnosis of cough may include spirometry to document or rule out asthma and reactive airways, and rhinoscopy to diagnose postnasal drip versus gastroesophageal reflux. Therefore, an allergy skin test is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in allergy and immunology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.