Print Allergy Immunotherapy

Allergy Immunotherapy

 

DESCRIPTION

Immunotherapy involves regular injections of an offending allergen over a period of months, with the goal of reducing symptoms. It begins with low doses to prevent unfavorable reactions, with gradually increasing doses injected once or twice a week as immunity to the antigen develops. After the maintenance dose is achieved, the interval between injections may range between two and six weeks. Immunotherapy may be administered continuously for several years.

Sublingual immunotherapy (SLIT) is a potential alternative to subcutaneous immunotherapy for providing allergen-specific therapy. It is proposed as a more convenient alternative delivery route for treating a variety of allergic disorders.

Allergen-specific immunotherapy involves administering well-characterized allergen extracts, the potencies of which are measured and compared with a reference standard. An initial induction or build-up phase progressively increases the allergen dose; this is followed by multiple years of maintenance injections at the highest dose. Allergen-specific immunotherapy has been used to treat a variety of conditions including insect allergy, allergic rhinitis, and asthma. Subcutaneous injection of allergen-specific immunotherapy is the standard approach. Due to the inconvenience of multiple injections, particularly in children, alternative delivery routes have been investigated; of these, sublingual immunotherapy (SLIT) is the most prominent. SLIT targets absorption to the sublingual and buccal mucosa. Allergen preparations used for SLIT are held under the tongue for one to several minutes and then swallowed or spit out.

 

POLICY

Immunotherapy is considered medically necessary in patients with demonstrated hypersensitivity that cannot be managed by medications or avoidance. Injections of airborne or insect venom allergens should be prepared for the patient individually.

Allergen immunotherapy should be paid by injection, not by dose. Provision of antigens for allergen immunotherapy will be paid by dose or vial, based on CPT descriptor.

The following methods are considered investigational and not covered:

  • Provocative and neutralization therapy for food allergies, using intradermal and subcutaneous routes
  • Sublingual
  • Urine autoinjections (autogenous urine immunization)
  • Repository emulsion therapy

Clinical ecology services may be billed as allergy services, and should be denied as investigational. These services involve the diagnosis and treatment of environmental illness, which is defined as multiple complex allergies or toxicities which are alleged to cause symptomatic involvement of the gastrointestinal, musculoskeletal, respiratory, or central nervous system. These symptoms result from continued exposure to atmospheric contamination or exposure to common foods which may have been treated with pesticides and herbicides.

Allergen-proof supplies, such as mattresses, mattress casings, pillows, pillow casings, air purification devices etc., should be considered personal convenience items and therefore are not medical in nature. These are routinely excluded as personal convenience items.

Examples of non-covered items considered to be used for environmental medicine/clinical ecology include but are not limited to:

  • Barrier cloth cover for mattress
  • Cold packs to keep antigens frozen
  • Electric heater, mineral oil sealed, dimplex
  • Half-mask respirator with organic vapor cartridges
  • Housecleaning services
  • Mold plates
  • Portable air filter with air conditioner converter
  • RainbowTM vacuum cleaner
  • Syringes for antigen injections
  • Water service

 

POLICY EXCEPTIONS

None

 

POLICY GUIDELINES

Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.

Allergen immunotherapy should be paid by injection, not by dose. Provision of antigens for allergen immunotherapy will be paid by dose or vial, based on CPT descriptor.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

 

POLICY HISTORY

9/1992: Issued

2/1997: Medical Policy Advisory Committee approved revision to pay by injection

5/23/2001: Code reference section updated; ICD-9 diagnosis codes 117.3, 496.7 and 708.3 deleted.

2/14/2002: Investigational definition added

4/18/2002: Type of Service and Place of Service deleted

6/5/2002: Code Reference section updated

6/12/2002: "Rinkel, also known as serial dilution endpoint titration therapy for ragweed pollen hay fever" statement deleted. See Allergy Testing policy. ICD-9 diagnosis codes added 117.3, 692.73, 692.89, 693.9, 708.3

4/11/2003: Sources updated

8/1/2003: CPT code ranges 95120-95134, 95144-95170 listed separately, ICD-9 diagnosis code ranges 477.0-477.9, 692.0-692.6, 692.72-692.74 listed separately, Sources updated

11/3/2004: Code Reference section updated, CPT code 95117 description revised, CPT code 95180 added covered codes, ICD-9 diagnosis code 477.2, 692.84, E906.4 added covered codes, ICD-9 diagnosis code V15.0 5th digit added covered codes, ICD-9 diagnosis code 989.5 deleted covered codes

9/12/2006:  Coding Updated.  ICD-9 2006 revisions added to policy

5/1/2008: Policy reviewed, no changes

9/30/2009: Code reference section updated. Code description revised for ICD9 diagnosis code V15.06. ICD-9 diagnosis code 995.2 deleted from covered table due to code is a deleted code as of 9-30-2006.

04/26/2010: Policy description revised to add information regarding sublingual immunotherapy (SLIT); however, this method remains investigational. Policy statement unchanged.

04/20/2011: Policy reviewed; no changes.

04/19/2012: Policy reviewed; no changes.

04/24/2013: Policy reviewed; no changes.

09/15/2014: Policy reviewed; no changes.

 

SOURCE(S)

Technology Evaluation and Coverage 1987; pp. 2 and 11

TEC Bulletin Vol 20, #1, 2003

Blue Cross Blue Shield Association policy #2.01.17

 

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.

Covered Codes

Code Number

Description

CPT-4

95115

Professional services for allergen immunotherapy, not including provision of allergenic extracts; single injection (administration only).

95117

Professional services for allergen immunotherapy not including provision of allergenic extracts; two or more injections (administration only)

95120

Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; single injection

95125

Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; two or more injections

95130

Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; single stinging insect venom

95131

Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; two stinging insect venoms

95132

Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; three stinging insect venoms

95133

Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; four stinging insect venoms

95134

Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; five stinging insect venoms

95144

Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single dose vial(s) (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); two single stinging insect venoms

95147

Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); three single stinging insect venoms

95148

Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); four single stinging insect venoms

95149

Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); five 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; whole body extract of biting insect or other arthropod (specify number of doses)

95180

Rapid desensitization procedure, each hour (eg, insulin, penicillin, equine serum)

ICD-9 Procedure

99.12

Immunization for allergy

ICD-9 Diagnosis

117.3

Aspergillosis

279.03

Immune deficiency Disease (IgE)

279.12

Wiskott-Aldrich syndrome

477.0, 477.1, 477.2, 477.8, 477.9

Allergic rhinitis code range

495.7

"Ventilation pneumonitis"

518.6

Aspergillosis (allergic bronchopulmonary)

692.0, 692.1, 692.2, 692.3, 692.4, 692.5, 692.6

Contact dermatitis and other eczema code range

692.72 

Acute dermatitis due to solar radiation

692.73 

Actinic reticuloid and actinic granuloma

692.74 

Other chronic dermatitis due to solar radiation

692.81

Dermatitis due to contact with cosmetics

692.82

Photosensitization due to radiation other than sun; i.e., infrared rays, x-rays, light

692.83

Dermatitis due to metals (i.e., jewelry)

692.84

Contact dermatitis and other eczema due to animal (cat, dog) dander

692.89 

Contact dermatitis and other eczema due to other specified agent

692.9

Contact dermatitis, unspecified cause

693.1

Dermatitis due to ingested food

693.8

Dermatitis due to other specified substance taken internally

693.9 

Dermatitis due to unspecified substance taken internally

694.5

Pemphigoid

708.0

Allergic urticaria

708.3

Dermatographic urticaria

995.20

Unspecified adverse effect of unspecified drug, medicinal and biological substance.

995.21

Arthus phenomenon

995.22

Unspecified adverse effect of anesthesia

995.23

Unspecified adverse effect of insulin

995.27

Other drug allergy

995.29

Unspecified adverse effect of other drug, medicinal and biological substance

995.3

Allergic reaction

E906.4 

Bite of nonvenomous arthropod

V15.01

Personal history of allergy to peanuts

V15.02 

Personal history of allergy to milk products

V15.03 

Personal history of allergy to eggs

V15.04 

Personal history of allergy to seafood

V15.05 

Personal history of allergy to other foods

V15.06 

Allergy to insects and arachnids  

V15.07 

Personal history of allergy to latex

V15.08 

Personal history of allergy to radiographic dye

V15.09 

Personal history of other allergy, other than to medicinal agents

V72.7

Encounter for diagnostic skin and sensitization tests

HCPCS

 

 

This is not an all-inclusive list of non-covered procedure codes.

The code(s) listed below and ANY code not listed in the previous section are considered non-covered for this procedure

Non-Covered Codes

Code Number

Description

CPT-4

95199

Unlisted allergy/clinical immunologic service or procedure [clinical ecology]

ICD-9 Procedure

 

 

ICD-9 Diagnosis

 

 

HCPCS

 

 

 

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