MEDICAL POLICY

POLICY
RELATED POLICIES
POLICY GUIDELINES
DESCRIPTION
SCOPE
BENEFIT APPLICATION
RATIONALE
REFERENCES
CODING
APPENDIX
HISTORY

Diagnosis and Management of Idiopathic Environmental Intolerance (i.e., Multiple Chemical Sensitivities)

Number 2.01.01*

Effective Date July 24, 2013

Revision Date(s) 07/08/13; 07/10/12; 07/12/11; 08/10/10; 03/10/09; 02/12/08; 08/08/06; 02/14/06; 06/14/05; 06/08/04; 10/16/03; 12/10/02; 04/04/00; 05/05/97

Replaces N/A

*Medicare has a policy.

Policy

Laboratory tests designed to affirm the diagnosis of idiopathic environmental intolerance are considered investigational. (see Policy Guidelines)

Treatments for idiopathic environmental intolerance, including but not limited to IVIg, neutralizing therapy of chemical and food extracts, avoidance therapy, elimination diets, and oral nystatin (to treat Candida), are considered investigational.

Related Policies

2.01.17

Sublingual Immunotherapy as a Technique of Allergen Specific Therapy

2.01.500

Allergy Testing

2.04.508

Fecal Analysis in the Diagnosis of Intestinal Dysbiosis

2.04.73

Intracellular Micronutrient Analysis

Policy Guidelines

Laboratory tests for the diagnosis of idiopathic environmental intolerance may be broadly subdivided into those intended to rule out specific diseases with well-defined presentations and diagnostic criteria and those tests designed to affirm the diagnosis of idiopathic environmental intolerance. For example, a basic diagnostic workup, including a standard panel of chemistry tests and blood work-up, would be considered appropriate as an initial diagnostic step, even in patients with non-specific symptoms, to rule out well -defined illnesses. Additional tests may be considered medically necessary in patients with more specific symptoms, suggestive, for example, of an autoimmune connective tissue disease, or infectious mononucleosis. A variety of psychiatric or psychologic assessments may be performed to assess underlying conditions. However, at the present time, no specific tests can confirm the diagnosis of idiopathic environmental intolerance, and thus, a large battery of tests performed for a patient with non-specific symptoms must be reviewed carefully for medical necessity.

For example, the following should be reviewed closely, particularly when ordered simultaneously: laboratory tests of immune function (i.e., lymphocyte transformation, deregulation of the 2,5A RNase L antiviral pathway), lymphocyte subsets (e.g., natural killer cells, CD4, CD8), immunoglobulin levels (e.g., IgG, IgE), levels of trace minerals in the serum or urine (e.g., selenium, manganese, mercury), antibodies for a variety of infectious agents simultaneously, allergy services (including provocation testing), positron emission tomography (PET) scans, or neuropsychologic testing and elaborate nutritional assessment, including intracellular micronutrient assays.

In addition, such treatments as immunoglobulin (IVIg) therapy, provocation therapy, or counseling regarding specific avoidance environments or elimination diets would be considered investigational in the absence of specific symptoms.

Description

Idiopathic environmental intolerance is typically characterized by recurrent, nonspecific symptoms that the patient or clinician believes are provoked by low levels of exposure to chemical, biologic, or physical agents. Reported symptoms are wide-ranging, and there are not clearly established diagnostic criteria. Various tests, e.g., nutritional assessment and treatment, e.g., immunoglobulin therapy (IVIg), have been proposed.

Background

Idiopathic environmental intolerance has been labeled in a variety of ways over time. The original term, clinical ecology, was replaced by the term multiple chemical sensitivity (MCS). More recently, MCS has been replaced by idiopathic environmental intolerance, a term that reflects the uncertain nature of the condition and its relationship to chemical exposure. The central focus of the condition is patient reporting of recurrent, nonspecific symptoms referable to multiple organ systems that the patient believes are provoked by exposure to low levels of chemical, biologic, or physical agents. The most common environmental exposures include perfumes and scented products, pesticides, domestic and industrial solvents, new carpets, car exhaust, gasoline and diesel fumes, urban air pollution, cigarette smoke, plastics, and formaldehyde. Certain foods, food additives, drugs, electromagnetic fields, and mercury in dental fillings have also been reported as triggering events. However symptoms do not bear any relationship to established toxic effects of the specific chemical and occur at concentrations far below those expected to elicit toxicity.

Reported symptoms are markedly variable but generally involve the central nervous system, respiratory and mucosal irritation, or gastrointestinal symptoms. Symptoms may include fatigue, difficulty in concentrating, depressed mood, memory loss, weakness, dizziness, headaches, heat intolerance, and arthralgia. In contrast to the frequently debilitating symptomatology, no specific and consistent abnormalities are noted on laboratory or other diagnostic testing Other primarily subjectively defined disorders have symptoms that overlap with idiopathic environmental intolerance, including chronic fatigue syndrome, sick building syndrome, fibromyalgia, irritable bowel syndrome, and Gulf War syndrome. A diagnosis of Intestinal dysbiosis could be considered within the category of idiopathic environmental intolerance. (Intestinal dysbiosis is addressed in a separate (See Related Policies)

The variable nature of the reported symptoms and the lack of recognized pathologic abnormalities make it extremely difficult to establish objective diagnostic criteria for the condition, which further hinders research into both the causes and appropriate treatment. Various causes for idiopathic environmental intolerances have been proposed; these have prompted different diagnostic and treatment approaches. Some believe that the condition is An unrecognized form of allergy or immunologic hypersensitivity. Advocates of this etiology may recommend a large series of immunologic tests, including a variety of provocation-neutralization tests and a panel of immunologic tests, including immune function tests (e.g., deregulation of the 2,5A RNase L antiviral pathway in peripheral mononuclear blood cells) and levels of lymphocyte subsets (i.e., natural killer cells, CD8 cells). Proposed therapies have included avoidance of exposure, either or both in the environment or in the diet. Immune Globulin may be recommended for injection or sublingual drops of “neutralizing” chemical and food extracts. Others have proposed that exposure to toxic substances may have prompted the immunologic abnormality and, based on this theory, testing of levels of environmental chemicals in the blood, urine, or fat may be suggested. Detailed nutritional analyses have also been performed, including levels of trace minerals in the blood, urine, or intracellular levels. Such elaborate nutritional assessments may also be performed in asymptomatic subjects. For example, Functional Intracellular Analysis (FIA™) is a series of laboratory tests offered by SpectraCell Labs that measure the intracellular levels of micronutrients, such as vitamins, minerals, and antioxidants in lymphocytes.

In some instances, symptoms may appear to coincide after exposure to a viral illness (particularly common in the related condition of chronic fatigue syndrome); supporters of this theory may recommend a wide variety of tests to detect antibodies or antigens of various viruses. Some have also suggested that hypersensitivity to Candida may present with a similar array of subjective complaints and thus recommend testing for Candida in the stool or urine. Finally, it has also been proposed that idiopathic environmental intolerance is a manifestation of a psychiatric disease or personality disorder based in part on results of psychological/psychiatric interviews.

It should be noted that some environmentally caused illnesses can be well -characterized by their clinical presentation and laboratory tests. For example, in certain instances, “sick building” syndrome can be traced back to exposure of microorganisms related to air-handling systems. However, in contrast to idiopathic environmental intolerances, these patients experience a limited range of symptoms, and those symptoms only occur in the affected building.

Note: The diagnosis of intestinal dysbiosis may overlap with idiopathic environmental intolerance. See related policies.

Regulatory Status

No specific U.S. Food and Drug Administration (FDA) approval or clearance of a test for idiopathic environmental intolerance was found.

Scope

Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply.

Benefit Application

N/A

Rationale

This policy was originally created in 1995 and was updated regularly with searches of the MEDLINE database. The most recent literature search was performed for the period March 2012 through March 20, 2013. Following is a summary of the key literature to date.

The clinical entity of idiopathic environmental intolerance has been controversial for decades, in part due to the lack of a set of reproducible diagnostic criteria. Absent a clear definition of the disorder, basic science research into the etiology of the disorder, appropriate laboratory tests, and identifications of effective treatment are obviously problematic. Published reviews and opinion pieces suggest controversy regarding the etiology of the condition, appropriate diagnostic criteria, and treatment strategies. (1-5)

Diagnosis

No well-designed studies were identified in the literature searches that evaluated the ability of laboratory tests, nutritional assessments, or other diagnostic tests to accurately diagnose idiopathic environmental intolerance (or MCS).

Studies to date have focused on developing reliable criteria for characterizing idiopathic environmental intolerance and defining an optimal approach to diagnosing the condition. In 2006, Das-Munshi et al. published a systematic review of provocation studies in individuals with multiple chemical sensitivity (MCS). (6) The investigators identified 37 studies that included a total of 784 patients who had been diagnosed with MCS. Blinding was inadequate in most cases. In eight of 11 studies that were described as double-blind but likely had discernible odors, individuals with MCS had positive responses to provocation. However, of the seven studies that used chemicals at or below the threshold of detectable odors, six failed to show consistent responses in patients with MCS after active provocation. In the three studies that used olfactory-masking agents to conceal the identity of the stimulus, none found associations between provocation and response. The authors concluded that persons with MCS react to chemical challenges when they can discern differences between active and sham substances, but when stimuli are adequately masked, individuals with MCS are unable to reliably identify active stimuli. The authors further commented that there may be psychological or behavioral factors leading individuals to have physiologic responses to stimuli when they are aware of the exposure. In reports from Europe, researchers have found that findings of psychological distress, the ability to express emotions, somatic attribution, amplification (susceptibility to sensation), and absorption (predisposition to become deeply immersed in sensory or mystical experiences) were related to the presence of idiopathic environmental intolerance. (7-11)

In 2008, Bornschein and colleagues published the findings of a double-blind, placebo-controlled provocation study, conducted in Germany that included 20 patients with MCS and 17 healthy controls matched for age and gender. (12) Patients with MCS met several sets of diagnostic criteria developed in the 1990s, including criteria for Idiopathic Environmental Intolerances defined by the International Program for Chemical Safety. Specific eligibility criteria included reporting symptoms that usually arise and recede within a time span of 10 minutes after the beginning of exposure and MCS symptoms that can be provoked by organic solvents. Provocations took place in a “climate chamber” (room for climatologic and chemical provocations). Participants underwent 6 consecutive 15-minute sessions, each followed by a 15-minute break. Three sessions were exposures to solvents and the other 3 were exposure to placebo (clean air), in random order; patients and staff were blinded. The solvents were a mixture of 6 hydrocarbons found in common household solvents; to avoid the need for olfactory masking, room air concentrations were set below a detectable odor threshold. Only one participant failed to complete the provocation sessions. A positive reaction to exposure was defined as 1) the individual believed he or she had been exposed to an active agent; 2) there was an objective sign of a reaction, e.g., rash, increase in heart rate; or 3) symptom severity rose to 3 or 4 (on 4-point scale). Fifty percent of patients with MCS and 53% of matched controls showed a positive reaction in all 6 exposure sections. Eighty-two percent of controls and 50% of patients had 3 correct reactions. However, more patients than controls (30% versus 12%, respectively) reacted correctly more than 3 times. Considering only the subjective perception of exposure, 40% of patients and 35% of controls voted correctly more than 3 times. Overall, study findings suggest that patients with MCS disorders cannot reliably distinguish between solvents and placebo.

Several systematic reviews of studies on the diagnosis of idiopathic environmental intolerance attributed to electromagnetic fields (EMF) have been published. A 2011 systematic review by Rubin and colleagues identified 29 studies which were single- or double-blind, exposed participants to EMF fields, and measured objective outcomes. (13) Twenty of the 29 studies used outcomes related to the autonomic nervous system (e.g., heart rate or blood pressure). Two of 20 (10%) studies found a significant impact of EMF on function and the other 18 studies found no effect. The authors noted that findings of the 2 positive studies might have been influenced by the order of exposure e.g. including a sham exposure that was always first or second in a series of 3 or 4 consecutive exposures. None of the 4 studies measuring blood chemistry or 3 studies measuring brain physiology found a significant effect of EMF levels on outcomes. Seven studies tested cognitive function; 2 of 7 (29%) had at least one positive finding. The authors concluded that there is insufficient evidence suggesting that individuals with idiopathic environmental intolerance attributed to EMF experience their physiological reactions as a result of exposure to EMF.

In 2012, Baliatsas and colleagues reviewed 63 studies that included definitions or criteria for identifying individuals with idiopathic environmental intolerance related to EMF exposure. (14) The major criteria used in the studies were: 1) attribution of non-specific physical symptoms to either various or specific sources of EMF (n=13 studies); 2) self-reported idiopathic environmental intolerance attributed to EMF exposure (or similar terms) (n=14 studies); 3) experience of symptoms during or within 24 hours after perceived or actual EMF exposure (n=10 studies); and 4) high score on a symptom scale (n=6). The review found considerable variation among studies in terms of definitions and criteria; uniform diagnostic criteria have not yet been developed.

Treatment

In 2012, Skovbjerg and colleagues in Denmark published a randomized non-blinded pilot study to evaluate mindfulness-based cognitive therapy to treat multiple chemical sensitivities. (15) Thirty-seven individuals with self-reported symptoms attributed to exposure to common airborne chemicals, or with physician-diagnosed MCS were included. Participants were randomized to receive weekly group therapy for 8 weeks or usual care. At the 4-, 8- and 12-week follow-ups, no statistically significant differences were found between groups in the 2 main outcome measures, the Symptom Checklist-92 (SCL-92) and the Brief Illness Perception Questionnaire (Brief IPQ). For example, 8 weeks after the beginning of the intervention, mean scores on the somatization scale of the SCL-92 were 0.78 in the therapy group and 0.79 in the control group (p=0.59)

Summary

There is a lack of clear diagnostic criteria for idiopathic environmental intolerance (also known as multiple chemical sensitivities) and a lack of evidence on the diagnostic accuracy of laboratory or other tests for this condition. Overall, studies using existing criteria have not found that individuals diagnosed with the condition can reliably distinguish between chemical exposure and placebo. Moreover, studies have not consistently found that low-level electromagnetic field exposure affects objective outcomes e.g. heart rate or cognitive function. In addition, there is a lack of controlled studies to evaluate treatments for idiopathic environmental intolerance. Thus, all tests and treatments for this condition are considered investigational.

Practice Guidelines and Position Statements

A variety of organizations have presented position papers on idiopathic environmental intolerance, previously referred to as multiple chemical sensitivity or clinical ecology.

In 1999, the American Academy of Allergy, Asthma and Immunology (AAAAI) issued a position statement on idiopathic environmental intolerance. This statement is still posted on the AAAAI website, but it has been archived. (16) The summary of the position states:

“IEI [idiopathic environmental intolerances]-also called environmental illness and multiple chemical sensitivities-has been postulated to be a disease unique to modern industrial society in which certain persons are said to acquire exquisite sensitivity to numerous chemically unrelated environmental substances Because of the subjective nature of the illness, an objective case definition is not possiblethere is an absence of scientific evidence to establish any of these mechanisms as definitive. Most studies to date, however, have found an excess of current and past psychopathology in patients with this diagnosis. The relationship of these findings to the patient's symptoms is also not apparent. Rigorously controlled studies to verify the patient's reported subjective sensitivity to specific environmental chemicals have yet to be done. Moreover, there is no evidence that these patients have any immunologic or neurologic abnormalities. In addition, no form of therapy has yet been shown to alter the patient's illness in a favorable way. A causal connection between environmental chemicals, foods, and/or drugs and the patient's symptoms continues to be speculative and cannot be based on the results of currently published scientific studies.”

In 1999, the American College of Occupational and Environmental Medicine (ACOEM) published a position statement (17) that concluded, in part:

“Although specific diagnostic test and treatment have not yet been demonstrated to be helpful, a generalized clinical approach useful in the management of other nonspecific medical syndromes can be adopted pending further scientific findings. This approach emphasizes 1) establishing a therapeutic alliance with a goal toward functional restoration; 2) performing a medical evaluation appropriate to the presenting complaints and physical findings; 3) avoiding ineffective, costly, and potentially hazardous, unproven diagnostic tests or remedies that may increase a patient’s distress or disease; 4) treating all diagnosable medical and psychological problems; 5) individualizing medical and behavioral coping strategies useful in managing symptoms; and 6) educating the patients about the current state of knowledge about MCS [multiple chemical sensitivity].”

Medicare National Coverage

No national coverage determination for idiopathic environmental intolerance or multiple chemical sensitivities.

References

  1. Aaron LA, Buchwald D. A review of the evidence for overlap among unexplained clinical conditions. Ann Intern Med 2001; 134(9 pt 2):868-81.
  2. Barsky AJ, Borus JF. Functional somatic syndromes. Ann Intern Med 1999; 130(11):910-21.
  3. Graveling RA, Pilkington A, George JP et al. A review of multiple chemical sensitivity. Occup Environ Med 1999; 56(2):73-85.
  4. Lacour M, Zunder T, Huber R et al. The pathogenetic significance of intestinal Candida colonization--a systematic review from an interdisciplinary and environmental medical point of view. Int J Hyg Environ Health 2002; 205(4): 257-68.
  5. Winder C. Mechanisms of multiple chemical sensitivity. Toxicol Lett 2002; 128(3-Jan):85-97.
  6. Das-Munshi J, Rubin GJ, Wessely S. Multiple chemical sensitivities: A systematic review of provocation studies. J Allergy Clin Immunol 2006; 118(6):1257-64.
  7. Bailer J, Witthoft M, Rist F. Psychological predictors of short- and medium term outcome in individuals with idiopathic environmental intolerance (IEI) and individuals with somatoform disorders. J Toxicol Environ Health A 2008; 71(11-12):766-75.
  8. Witthoft M, Rist F, Bailer J. Evidence for a specific link between the personality trait of absorption and idiopathic environmental intolerance. J Toxicol Environ Health A 2008; 71(11-12):795-802.
  9. Skovbjerg S, Zachariae R, Rasmussen A et al. Attention to bodily sensations and symptom perception in individuals with idiopathic environmental intolerance. Environ Health Prev Med 2010; 15(3):141-50.
  10. Skovberg S, Zachariae R, Rasumussen R et al. Regressive coping and alexithymia in idiopathic environmental intolerance. Environ Health Prev Med 2010; 15(5):299-310.
  11. Skovbjerg S, Rasmussen A, Zachariae R et al. The association between idiopathic environmental intolerance and psychological distress, and the influence of social support and recent major life events. Environ Health Prev Med 2012; 17(1):2-9.
  12. Bornschein S, Hausteiner C, Rommelt H et al. Double-blind placebo-controlled provocation study in patients with subjective Multiple Chemical Sensitivity (MCS) and matched control subjects. Clin Toxicology 2008; 46(5):443-9.
  13. Rubin GJ, Hillert L, Nieto-Hernandez R et al. Do people with idiopathic environmental intolerance attributed to electromagnetic fields display physiological effects when exposed to electromagnetic fields A. systematic review of provocation studies. Bioelectromagnetics 2011; 32(8):593-609.
  14. Baliatsas C, Van Kamp I, Lebret E et al. Idiopathic environmental intolerance attributed to electromagnetic fields (IEI-EMF): a systematic review of identifying criteria. BMC Public Health 2012; 12:643.
  15. Skovbjerg S, Hauge CR, Rasmussen A et al. Mindfulness-based cognitive therapy to treat multiple chemical sensitivities: a randomized pilot trial. Scand J Psychol 2012; 53(3):233-8.
  16. American Academy of Allergy Asthma and Immunology Position Statement on Idiopathic Environmental Intolerances. 1999. Available online at: http://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/Practice%20and%20Parameters/Idiopathic-environmental-intolerances-1999.pdf. Last accessed June 11, 2013.
  17. American College of Occupational Environmental Medicine Position Statement. Multiple chemical sensitivities: Idiopathic environmental intolerance. J Occup Environ Med 1999; 41(11):940-2.Blue Cross and Blue Shield Association Medical Policy Reference Manual. Diagnosis and Management of idiopathic Environmental Intolerance (i.e., Multiple Chemical Sensitivities). Medical Policy Reference Manual, Policy 2.01.01, 2013

Coding

Codes

Number

Description

CPT

 

A wide variety of laboratory and other diagnostic tests; see Policy Guidelines above.

ICD-9 Procedure

   

ICD-9 Diagnosis

 

The following ICD-9 codes are listed in the section on “Symptoms, Signs, and Ill-Defined Conditions”

 

780.4

Dizziness and giddiness

 

780.79

Other malaise and fatigue

 

780.91 – 780.99

Other general symptoms, code range

 

781.1

Disturbances of sensation of smell and taste

 

786.00

Respiratory abnormality, unspecified

 

786.01

Hyperventilation

 

786.02

Orthopnea

 

786.03

Apnea

 

786.04

Cheyne-Stokes respiration

 

786.05

Shortness of breath

 

786.06

Tachypnea

 

786.07

Wheezing

 

786.09

Other

 

786.1

Stridor

 

786.2

Cough

 

786.3

Hemoptysis

 

786.4

Abnormal sputum

 

786.5

Chest pain

 

786.50

Chest pain, unspecified

 

786.51

Precordial pain

 

786.52

Painful respiration

 

786.59

Other

 

786.6

Swelling, mass or lump in chest

 

786.7

Abnormal chest sounds

 

786.8

Hiccough

 

786.9

Other symptoms involving respiratory system and chest

 

787.0

Nausea and vomiting

 

787.01

Nausea with vomiting

 

787.02

Nausea alone

 

787.03

Vomiting alone

 

787.1

Heartburn

 

787.2

Dysphagia

 

787.3

Flatulence, eructation, and gas pain

 

787.4

Visible peristalsis

 

787.5

Abnormal bowel sounds

 

787.6

Incontinence of feces

 

787.7

Abnormal feces

 

787.9

Other symptoms involving digestive system

   

The following ICD-9 codes are listed in the section on “Poisoning by Drugs, Medicinal, and Biological Substances”

 

960.0

Poisoning by antibiotics : Penicillins

 

960.1

Antifungal antibiotics

 

960.2

Chloramphenicol group

 

960.3

Erythromycin and other macrolides

 

960.4

Tetracycline group

 

960.5

Cephalosporin group

 

960.6

Antimycobacterial antibiotics

 

960.7

Antineoplastic antibiotics

 

960.8

Other specified antibiotics

 

960.9

Unspecified antibiotic

 

961.0 - 9

Poisoning by other anti-infectives

 

962.0 - 9

Poisoning by hormones and synthetic substitutes

 

963.0 - 9

Poisoning by primarily systemic agents

 

964.0 - 9

Poisoning by agents primarily affecting blood constituents

 

965.0 - 9

Poisoning by analgesics, antipyretics, and antirheumatics

 

966.0 - 9

Poisoning by anticonvulsants and anti-Parkinsonism drugs

 

967.0 - 9

Poisoning by sedatives and hypnotics

 

968.0 - 9

Poisoning by other central nervous system depressants and anesthetics

 

969.0 - 9

Poisoning by psychotropic agents

 

970.0 - 9

Poisoning by central nervous system stimulants

 

971.0 - 9

Poisoning by drugs primarily affecting the autonomic nervous system

 

972.0 - 9

Poisoning by agents primarily affecting the cardiovascular system

 

973.0 - 9

Poisoning by agents primarily affecting the gastrointestinal system

 

974.0 - 9

Poisoning by water, mineral, and uric acid metabolism drugs

 

975.0 - 8

Poisoning by agents primarily acting on the smooth and skeletal muscles and respiratory system

 

976.0 - 9

Poisoning by agents primarily affecting skin and mucous membrane, ophthalmological, otorhinolaryngological, and dental drugs

 

977.0 - 9

Poisoning by other and unspecified drugs and medicinal substances

 

978.0 - 9

Poisoning by bacterial vaccines

 

979.0 - 9

Poisoning by other vaccines and biological substances

   

The following ICD-9 codes are listed in the section on “Toxic Effects of Substances Chiefly Nonmedicinal as to Source”

 

980.0 - 9

Toxic effect of alcohol

 

981

Toxic effect of petroleum products

 

982.0 - 8

Toxic effect of solvents other than petroleum-based

 

983.0 - 9

Toxic effect of corrosive aromatics, acids, and caustic alkalis

 

984.0 - 9

Toxic effect of lead and its compounds (including fumes)

 

985.0 - 9

Toxic effect of other metals

 

986

Toxic effect of carbon monoxide

 

987.0 - 9

Toxic effect of other gases, fumes, or vapors

 

988.0 - 9

Toxic effect of noxious substances eaten as food

 

989.0 - 9

Toxic effect of other substances, chiefly nonmedicinal as to source

ICD-10-CM (effective 10/1/14)

R00.0 - R09.89

Symptoms and signs involving the circulatory and respiratory systems, code range

 

R10.0 - R19.8

Symptoms and signs involving the digestive system and abdomen, code range

 

R42

Dizziness and giddiness

 

R43.0 - R43.9

Disturbances of smell and taste, code range

 

R50.2 - R69

General symptoms and signs, code range

 

T36.0x1 - T50.996

Poisoning by adverse effect of and underdosing of drugs, medicaments and biological substances, code range

 

T51.0x1 - T65.94

Toxic effects of substances chiefly nonmedicinal as to source, code range

ICD-10-PCS (effective 10/1/14)

   

HCPCS

   

Type of Service

Medical

 

Place of Service

Outpatient

Physician’s Office

 

Appendix

N/A

History

Date

Reason

05/05/97

Add to Medicine Section - New Policy

04/04/00

Replace Policy - Scheduled review; no criteria changes.

12/10/02

Replace Policy - Policy updated with literature review; policy retitled to reflect evolving terminology; expanded discussion and rationale section; more specific policy statement and policy guidelines, but underlying policy statement essentially unchanged.

10/16/03

Replace Policy - Policy updated with literature review; no change in policy statement.

06/08/04

Replace Policy - Policy reviewed; information included on micronutrient analysis as investigational added.

06/14/05

Replace Policy - Policy updated with literature review; no change in policy statement.

02/14/06

Replace Policy - Policy updated with literature review; no change in policy statement. Title changed by adding “Diagnosis and Management of …”

06/16/06

Update Scope and Disclaimer - No other changes.

08/08/06

Replace Policy - Policy updated with literature review; information on RNase added; no change in policy statement.

02/12/08

Replace Policy - Policy updated with literature review; no change in policy statement. References added.

03/10/09

Replace Policy - Policy updated with literature search; no change to the policy statement. References added.

08/10/10

Replace Policy - Policy updated with literature search through March 2010. Rationale rewritten; reference numbers 11 and 13 added; other references re-numbered/removed. For clarification and consistency, in policy statements, idiopathic environmental illness changed to idiopathic environmental intolerance.

07/12/11

Replace Policy - Policy updated with literature search through March 2011. Reference numbers 12 and 13 added; other references renumbered. No change to policy statements. ICD-10 codes added to policy.

09/23/11

Related Policies updated; 2.04.73 added.

07/20/12

Replace policy. Policy updated with literature search through March 2012. Reference 17 added; other references renumbered/removed. The term “clinical ecology” in title removed and replaced with “multiple chemical sensitivities”. Policy statement on nutritional assessments, including intracellular analysis of micronutrients removed; this is addressed in Related Policy 2.04.73 Intracellular Micronutrient Analysis.

08/24/12

Update Coding Section – ICD-10 codes are now effective 10/01/2014.

07/24/13

Replace policy. Policy statement on treatment of idiopathic environmental intolerance modified for clarification. Rationale updated based on a literature review through March 2013. References 14 and 15 added; others renumbered/removed. Policy statement clarified as noted, intent unchanged – testing and treatment remains investigational.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
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