Allergy Immunotherapy - CAM 009HB

Description:
Allergic or hypersensitivity disorders may be manifested by generalized systemic reactions as well as localized reactions in any part of the body. Allergy sensitivity tests describe the performance and evaluation of selective cutaneous and mucous membrane tests in correlation with history, physical examination and other observations of the patient. Immunotherapy involves regular injections into the body of an offending allergen over a period of months with the goal of reducing the abnormal allergic symptoms. Therapy begins with low doses to prevent untoward reactions while gradually increasing doses as immunity to the antigen develops. Once maintenance dose is achieved, the interval between injections may range from two to six weeks. Immunotherapy may have to be continued for several years.

Policy:

When ordered by a board certified allergist or board certified ENT the following may be considered MEDICALLY NECESSARY:

Supervision (including preparation) and provision of 150 allergen/antigen preparations or less per 12 months of subcutaneous allergy immunotherapy is considered MEDICALLY NECESSARY for the first year, including the build-up phase. (CPT 95165)

Supervision (including preparation) and provision of 120 allergen/antigen preparations or less per 12 months of subcutaneous allergy immunotherapy is considered MEDICALLY NECESSARY after the first year as maintenance therapy. (CPT 95165)

Immunotherapy is appropriate for the treatment of these IgE medicated allergies:

Allergic (extrinsic) asthma
Hymenoptera (bees, wasps, ants) sensitive individuals
Mold-induced allergic rhinitis
Perennial rhinitis
Seasonal allergic rhinitis or conjunctivitis

When ALL of these conditions are met:

The patient has symptoms of allergic rhinitis and/or asthma after natural exposure to the allergen and/or the patient has a life-threatening allergy to insect stings (bees, wasps, ants).
The patient has skin test and/or serologic evidence of IgE mediated antibody to a potent extract of the antigen.
The allergic symptoms are refractory to avoidance and/or pharmacologic (drug) therapy.

Allergy Immunotherapy is NOT COVERED for:

Food allergy treatment.
Migraine headaches.
Nonallergic vasomotor rhinitis.
Intrinsic (nonallergic) asthma.
Chronic urticaria or atopic dermatitis.
Angioedema.

The following allergy treatments have not been proven to be effective, and, therefore, continue to be NONCOVERED:

Acupuncture for allergies
Allergoids (modification of allergens to reduce allergencity)
Detoxificationfor allergies
Enzyme potentiated desensitization (EDP)
Homeopathy for allergies
Photoinactivated extracts
Polymerized extracts
Poison ivy/poison oak extracts for immunotherapy in the prevention of toxicodendron (Rhus) dermatitis
IV vitamin therapy
Low dose desensitization

Allergen-proof supplies, such as mattresses, mattress casings, pillows, pillow casings, etc., are considered to be personal comfort items and, therefore, are non-covered. These supplies can be used for nonmedical purposes and are NOT CONSIDERED MEDICALLY NECESSARY for the treatment of illness.

Subcutaneous immunotherapy performed in the home setting is considered INVESTIGATIONAL.

Allergy immunotherapy ordered by providers other than board-certified allergists or board-certified ENT physicians is considered NOT MEDICALLY NECESSARY.

References:

Beyer K, Teuber SS. Food allergy diagnostics: Scientific and unproven procedures. Curr Opin Allergy Clin Immunol. 2005;5(3):261-266.
Baena-Cagnani CE, Passalacqua G, Baena-Cagnani RC, et al. Sublingual immunotherapy in pediatric patients: Beyond clinical efficacy. Curr Opin Allergy Clin Immunol. 2005;5(2):173-177.
Reider N. Sublingual immunotherapy for allergic rhinoconjunctivitis — the seeming and the real. Int Arch Allergy Immunol. 2005;137(3):181-186.
Dretzke J, Song F. Provocation-neutralisation testing and therapy for food allergy. Birmingham, UK: West Midlands Health Technology Assessment Collaboration, Department of Public Health and Epidemiology, University of Birmingham (WMHTAC); 2004: 1-105.
Koreck AI, Csoma Z, Bodai L, et al. Rhinophototherapy: A new therapeutic tool for the management of allergic rhinitis. J Allergy Clin Immunol. 2005;115(3):541-547.
Leimgruber A. Allergo-immunology. Rev Med Suisse.

Coding Section

Codes	Number	Description
CPT	95115	Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection
	95117	Professional services for allergen immunotherapy not including provision of allergenic extracts; 2 or more injections
	95120	Professional services for allergen immunotherapy in the office or institution of the prescribing physician or other qualified health care professional, including provision of allergenic extract; single injection
	95125	Professional services for allergen immunotherapy in the office or institution of the prescribing physician or other qualified health care professional, including provision of allergenic extract; 2 or more injections
	95130	Professional services for allergen immunotherapy in the office or institution of the prescribing physician or other qualified health care professional, including provision of allergenic extract; single stinging insect venom
	95131	Professional services for allergen immunotherapy in the office or institution of the prescribing physician or other qualified health care professional, including provision of allergenic extract; 2 stinging insect venoms
	95132	Professional services for allergen immunotherapy in the office or institution of the prescribing physician or other qualified health care professional, including provision of allergenic extract; 3 stinging insect venoms
	95133	Professional services for allergen immunotherapy in the office or institution of the prescribing physician or other qualified health care professional, including provision of allergenic extract; 4 stinging insect venoms
	95134	Professional services for allergen immunotherapy in the office or institution of the prescribing physician or other qualified health care professional, including provision of allergenic extract; 5 stinging insect venoms
	95144	Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy, single or multiple antigens, single dose vials (specify number of vials)
	95145	Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); single stinging insect venom
	95146	Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); 2 single stinging insect venoms
	95147	Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); 3 single stinging insect venoms
	95148	Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); 4 single stinging insect venoms
	95149	Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); 5 single stinging insect venoms
	95165	Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses)
	95170	Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); whole body extract of biting insect or other arthropod (specify number of doses)
	95180	Rapid desensitization procedure, each hour (e.g., insulin, penicillin, equine serum)
	95199	Unlisted allergy/clinical immunologic service or procedure

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.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

History From 2024 Forward

10/15/2024	Annual review, no change to policy intent.
04/03/2024	Interim review, removing the following direction relating to CPT 95165: Immunotherapy is considered MEDICALLY NECESSARY in patients with demonstrated hypersensitivity that cannot be managed by medications or avoidance. To ensure the potency and efficacy of the antigens, the provision of multiple-dose vials (CPT 95165) is restricted to sufficient antigen for not more than 120 doses in a 12-MONTH period, with 30 doses per 90 days allowed for a total of 120 doses per 12-month period, when ordered by a board-certified allergist or board-certified allergist or board-certified ENT physician. (NOTE: The number of doses is not the same as the number of antigens in each dose; this policy does not address the number of antigens being administered). Prior to the provision of additional antigens, there may be an evaluation and management service (99212-99215) documenting the review of the therapy record. Adding the following replacement statement: When ordered by a board certified allergist or board certified ENT the following may be considered medically necessary: Supervision (including preparation) and provision of 150 allergen/antigen preparations or less per 12 months of subcutaneous allergy immunotherapy is considered medically necessary after the first year, including the build-up phase. (CPT 95165) Supervision (including preparation) and provision of 120 allergen/antigen preparations or less per 12 months of subcutaneous allergy immunotherapy is considered medically necessary after the first year as maintenance therapy.(CPT 95165)
01/01/2024	New Policy

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Allergy Immunotherapy - CAM 009HB