Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.
Blue Cross and Blue Shield of Montana (BCBSMT) may consider the lymphocyte transformation test (i.e., Lymphocyte Mitogen Response test or the PHE Stimulation test) medically necessary for the following:
- Diagnosis and management of:
- Chronic mucocutaneous candidiasis; OR
- Congenital or acquired immunodeficiency disorders; OR
- Severe combined immune deficiency; OR
- DiGeorge anomaly; OR
- Nezelof syndrome; OR
- As an aid in the following applications:
- Studying the integrity of lymphokine production; OR
- Monitoring immunosuppressive or immunoenhancing therapy; OR
- Predicting allograft compatibility in the transplantation setting.
In addition, it is expected that the results of this test will be used in the management of the patient.
BCBSMT considers the lymphocyte transformation test for indications other than those listed above not medically necessary.
The lymphocyte transformation test is considered not medically necessary as a screening test.
Lymphocyte transformation tests are used for many reasons. Some uses are considered not medically necessary, such as its use as a screening test and to monitor cancer, occupational exposure to dust and other antigens, and other environmental antigens and mitogens. This policy addresses the situations where the use of this test would be considered appropriate.
A search of the literature was completed through MedLine database for the period of January 2000 through March 2007. No additional published studies were identified that would prompt reconsideration of the policy statement, which remains unchanged. The use of the lymphocyte transformation has not been proven to improve outcomes when used as a screening tool.
A search of peer-reviewed literature through August 2009 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.
A search of peer reviewed literature through February 2012 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.
Disclaimer for coding information on Medical Policies
Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.
The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.
Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.