Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

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 measurementshould 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. These recommendations are consistent with previous publications including a statement from the European Academy of Allergy and Clinical Immunology (EAACI) where testing of IgG4 to foods is considered as irrelevant for the laboratory work-up of food allergy or intolerance and should not be performed in case of food-related complaints. In addition, allergen immunotherapy (AIT) is a method to treat food allergy in which small doses of the triggering allergen are given in gradually escalating doses to induce a state of desensitization with regular, prescribed dosing. Currently, methods of immunotherapy for foods with the most significant data in the literature include oral immunotherapy (OIT), epicutaneous immunotherapy (EPIT) and SLIT. OIT involves ingestion of escalating doses of food, and SLIT typically involves smaller doses taken via sublingual route. These treatments may increase the amount of food that is tolerated, potentially reducing allergic symptoms and the risk of life-threatening reactions. A number of studies have shown promising results for OIT with a variety of foods, including peanut. OIT appears effective in inducing desensitization in a large number of patients in these studies, though adverse events, do occur. However, the data for SLIT is limited and in the few head-to-head studies, SLIT appeared less effective than OIT. Further, the most recent practice parameters developed in coordination with the American Academy of Allergy, Asthma and Immunology and the American College of Allergy, Asthma and Immunology, noted that SLIT has shown early promising results to decrease sensitization with low side effect profiles during treatment for peanut allergy, but protective desensitization is significantly less than with OIT. Given these findings, the requested SLIT is not likely to be beneficial to this patient, compared with standard therapies, including strict avoidance. All told, the laboratory testing for allergies (CPT code 86001); and SLIT allergen extract drops were not and are not likely to be more beneficial for evaluation and treatment of the patients medical condition. Final Result: Two of the three reviewers determined that the services and medication at issue were not and are not likely to be more beneficial for treatment and evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in allergy and immunology with subspecialty certification in pediatrics and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certifications in allergy and  immunology and rheumatology and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certification in allergy and immunology and is actively practicing.  All three reviewers are experts 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.