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.
Allergy immunotherapy may be considered medically necessary when ALL of the following criteria are met:
Individuals must be evaluated every six (6) to twelve (12) months while receiving allergy immunotherapy for ALL of the following indications:
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:
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.
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:
Covered Diagnosis Codes for Procedure Codes: 95115, 95117, 95120, 95125, 95130, 95131, 95132, 95133, 95134, 95144, 95145, 95146, 95147, 95148, 95149, 95165, 95170 and 95180
Quantity level limits or quantity of supplies that exceed the frequency guidelines listed on the policy will be denied as not medically necessary.