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Medical & Coding Policies
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DESCRIPTIONImmunotherapy 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.
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POLICYImmunotherapy 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:
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:
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POLICY EXCEPTIONSNone
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POLICY GUIDELINESInvestigative 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.
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POLICY HISTORY9/1992: Issued2/1997: 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.
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SOURCE(S)Technology Evaluation and Coverage 1987; pp. 2 and 11Hayes Medical Technology Directory TEC Bulletin Vol 20, #1, 2003 Blue Cross Blue Shield Association policy #2.01.17
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CODE REFERENCEThis is not intended to be a comprehensive list of codes. Some covered procedure codes have multiple descriptions.The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document. Covered Codes
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
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