Allergy Immunotherapy

Section: Injections
Effective Date: January 01, 2020
Revised Date: January 22, 2020
Last Reviewed: January 22, 2020

Description

Allergen 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.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person’s unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

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

  • An individual has ANY ONE of the following conditions:
    • Asthma; or
    • Allergic rhinitis; or
    • Allergic conjunctivitis; or
    • Stinging insect allergy (hymenoptera); or
    • Clinical evidence of an inhalant allergen sensitivity.

And

  • 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 ONE 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.

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.

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 Codes

95165

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

  • Food Allergy
  • Chronic Urticaria
  • Angioedema
  • 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 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 Z51.89 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

NA

ND Committee Review

Internal Medical Policy Committee 1-22-2020 Coding update

Links

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.