Allergy Immunotherapy

Policy ID: I-3-030

Section: Injections

Effective Date: July 01, 2018

Revised Date: May 20, 2024

Revision Effective Date: July 01, 2024

Last Reviewed: May 14, 2024

Applies To: Commercial and Medicaid Expansion

Description

Allergy immunotherapy or subcutaneous immunotherapy (SCIT) (also known as desensitization, hyposensitization, allergy injection therapy, or allergy shots), is the repeated administration of specific allergens to individuals with immune globulin E(IgE)-mediated conditions. The aim is to modify or stop the allergy by reducing the strength of the IgE response. Five (5) years of age is the youngest recommended age to start immunotherapy; however, there is no upper age limit for receiving immunotherapy.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date and

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.*See below to determine whether the policy rules apply to initial and adjustment claims based on date of processing (DOP) or Date of Service (DOS).

Criteria

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

Allergy immunotherapy may be considered medically necessary when the following criteria are met:

An individual has ANY of the following conditions:
- Asthma; or
- Allergic rhinitis; or
- Allergic conjunctivitis; or
- Stinging insect allergy (hymenoptera- bees, hornets, wasps, fire ants); or
- Clinical evidence of an inhalant allergen sensitivity; and
Individual meets ALL of the following criteria:
- Documented skin test and/or serologic evidence of IgE-mediated antibody to a potent extract of the allergen IgE test; and
- Avoidance or pharmacologic therapy cannot control allergic symptoms or individual has unacceptable side effects with pharmacologic therapy; and
- The individual's medical record documents the antigens to be administered, the treatment plan, and the dosage regimen. The regimen must include the starting immunotherapy schedule, target maintenance dose, and immunotherapy schedule.

Individuals must be evaluated every six (6) to 12 months while receiving allergy immunotherapy for ALL of the following indications:

To determine efficacy; and
To determine whether adjustments in the dosing schedule or allergen content are necessary; and
To ensure compliance; and
To monitor for the two (2) types of adverse reactions: local (i.e., redness and swelling at the injection site) and systemic (i. e., sneezing, nasal congestion, or hives).

Allergy immunotherapy is considered not medically necessary after one (1) year in the maintenance phase if ANY of the following signs of improvement is not experienced, when all other reasonable factors have been ruled out:

A noticeable decrease of symptoms; or
An increase in tolerance to the offending allergen; or
A reduction in medication usage.

Allergy immunotherapy not meeting the criteria as listed in this policy is considered not medically necessary.

Procedure Codes

95115

95117

95120

95125

95130

95131

95132

95133

95134

95144

95145

95146

95147

95148

95149

95165

95170

95180

Preparation and Provision of antigens

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

Supervision of preparation and provision of single or multiple antigens for allergen immunotherapy may be considered medically necessary for a cumulative total of 150 doses/units per benefit period for the first year, including the build-up phase.

Supervision of preparation and provision of single or multiple antigens for allergen immunotherapy may be considered medically necessary for a cumulative total of 120 doses/units per benefit period after the first year as maintenance therapy.

A dose/unit of antigen is defined as one (1)-cc aliquot from a multi-dose vial.

Supervision of preparation and provision of single or multiple antigens for allergen immunotherapy represents single or multiple-dose vials of non-venom antigens. Common practice for mixing a multi-dose vial of antigens is to prepare a ten (10)-cc vial then remove one (1)-cc doses.

Procedure Code

95165

Experimental/Investigational

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Allergy immunotherapy for the following is considered experimental/investigational and, therefore, non-covered, because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature:

Food Allergy [excluding FDA approved medications (e.g., peanut Arachis hypogaea allergen powder-dnfp (Palforzia), etc.]; and
Chronic Urticaria; and
Angioedema; and
Sublingual immunotherapy (SLIT) administered as drop formulation.

Procedure Codes

95115

95117

95120

95125

95130

95131

95132

95133

95134

95144

95145

95146

95147

95148

95149

95165

95170

95180

95199

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes: 95115, 95117, 95120, 95125, 95130, 95131, 95132, 95133, 95134, 95144, 95145, 95146, 95147, 95148, 95149, 95165, 95170, 95180

E905.3

H10.10

H10.11

H10.12

H10.13

H10.44

H10.45

J30.0

J30.1

J30.2

J30.81

J30.89

J30.9

J45.20

J45.21

J45.30

J45.31

J45.40

J45.41

J45.50

J45.51

J45.901

J45.902

J45.909

J45.991

J45.998

J82.81

J82.82

J82.89

T63.421A

T63.421D

T63.421S

T63.441A

T63.441D

T63.441S

T63.451A

T63.451D

T63.451S

T63.461A

T63.461D

T63.461S

T78.40XA

T78.40XD

T78.40XS

T78.49XA

T78.49XD

T78.49XS

Z51.6

Z91.030

Z91.038

Quantity level limits or quantity of supplies that exceed the frequency guidelines listed on the policy will be denied as not medically necessary.

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020 Coding update

Added new codes Z91.030 & Z91.038 (bee & insect bites)

Internal Medical Policy Committee 8-10-2020

Added Statement under Food Allergy except for FDA recommended medications (clarification statement).

Internal Medical Policy Committee 9-21-2020 Coding update

Removed Diagnosis code J82; and
Added J82.81; J82.82 and J82.89

Internal Medical Policy Committee 9-28-2022 Revision with Coding update

Removed Procedure code 95199
Updated with clarifying language

Internal Medical Policy Committee 3-23-2023 Coding Update- Effective May 01, 2023

Removed Diagnosis code Z51.89

Internal Medical Policy Committee 5-23-2023 Coding Update -Effective May 4, 2023

Added procedure code 95199

Internal Medical Policy Committee 3-19-2024-Annual Review-no changes in criteria

Added Policy Application

Internal Medical Policy Committee 5-14-2024 Revision -Effective July 1, 2024

Added Policy Application
Added QLL of 150 doses/units per benefit period for the first year, including the build-up phase
Changed 120 doses/units per benefit period to 120 doses/units per benefit period after the first year as maintenance therapy.

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: I-3-029

Section: Injections

Effective Date: July 01, 2018

Revised Date: May 04, 2023

Revision Effective Date: May 06, 2024

Last Reviewed: March 19, 2024

Archived Date: June 30, 2024

Applies To: Commercial and Medicaid Expansion

Description

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

Criteria

Allergy immunotherapy may be considered medically necessary when the following criteria are met:

An individual has ANY of the following conditions:
- Asthma; or
- Allergic rhinitis; or
- Allergic conjunctivitis; or
- Stinging insect allergy (hymenoptera– bees, hornets, wasps, fire ants); or
- Clinical evidence of an inhalant allergen sensitivity; and
Individual meets ALL of the following criteria:
- Documented skin test and/or serologic evidence of IgE-mediated antibody to a potent extract of the allergen IgE test; and
- Avoidance or pharmacologic therapy cannot control allergic symptoms or individual has unacceptable side effects with pharmacologic therapy; and
- The individual’s medical record documents the antigens to be administered, the treatment plan, and the dosage regimen. The regimen must include the starting immunotherapy schedule, target maintenance dose, and immunotherapy schedule.

Individuals must be evaluated every six (6) to 12 months while receiving allergy immunotherapy for ALL of the following indications:

To determine efficacy; and
To determine whether adjustments in the dosing schedule or allergen content are necessary; and
To ensure compliance; and
To monitor for the two (2) types of adverse reactions: local (i.e., redness and swelling at the injection site) and systemic (i. e., sneezing, nasal congestion, or hives).

A noticeable decrease of symptoms; or
An increase in tolerance to the offending allergen; or
A reduction in medication usage.

Allergy immunotherapy not meeting the criteria as listed in this policy is considered not medically necessary.

Procedure Codes

95115

95117

95120

95125

95130

95131

95132

95133

95134

95144

95145

95146

95147

95148

95149

95165

95170

95180

Supervision of preparation and provision of single or multiple antigens for allergen immunotherapy may be considered medically necessary for a cumulative total of 120 doses/units per benefit period.

A dose/unit of antigen is defined as one (1)-cc aliquot from a multi-dose vial.

Procedure Codes

95165

Food Allergy [excluding FDA approved medications (e.g., peanut Arachis hypogaea allergen powder-dnfp (Palforzia), etc.]; and
Chronic Urticaria; and
Angioedema; and
Sublingual immunotherapy (SLIT) administered as drop formulation.

Procedure Codes

95115

95117

95120

95125

95130

95131

95132

95133

95134

95144

95145

95146

95147

95148

95149

95165

95170

95180

95199

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes: 95115, 95117, 95120, 95125, 95130, 95131, 95132, 95133, 95134, 95144, 95145, 95146, 95147, 95148, 95149, 95165, 95170, 95180

E905.3

H10.10

H10.11

H10.12

H10.13

H10.44

H10.45

J30.0

J30.1

J30.2

J30.81

J30.89

J30.9

J45.20

J45.21

J45.30

J45.31

J45.40

J45.41

J45.50

J45.51

J45.901

J45.902

J45.909

J45.991

J45.998

J82.81

J82.82

J82.89

T63.421A

T63.421D

T63.421S

T63.441A

T63.441D

T63.441S

T63.451A

T63.451D

T63.451S

T63.461A

T63.461D

T63.461S

T78.40XA

T78.40XD

T78.40XS

T78.49XA

T78.49XD

T78.49XS

Z51.6

Z91.030

Z91.038

Quantity level limits or quantity of supplies that exceed the frequency guidelines listed on the policy will be denied as not medically necessary.

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020 Coding update

Added new codes Z91.030 & Z91.038 (bee & insect bites)

Internal Medical Policy Committee 8-10-2020

Added Statement under Food Allergy except for FDA recommended medications (clarification statement).

Internal Medical Policy Committee 9-21-2020 Coding update

Removed Diagnosis code J82; and
Added J82.81; J82.82 and J82.89

Internal Medical Policy Committee 9-28-2022 Revision with Coding update

Removed Procedure code 95199
Updated with clarifying language

Internal Medical Policy Committee 3-23-2023 Coding update-Effective May 01, 2023

Removed Diagnosis code Z51.89

Internal Medical Policy Committee Coding Update-Effective May 4, 2023

Add procedure code 95199

Internal Medical Policy Committee 3-19-2024-Annual Review-no changes in criteria

Added Policy Application

Links

References (PDF)

Disclaimer

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