Mountain State Medical Policy Bulletin
Section: Injections
Number: I-3
Topic: Allergy Immunotherapy
Effective Date: August 1, 2005
Issued Date: August 1, 2005
Date Last Reviewed: 06/2005

General Policy Guidelines

Indications and Limitations of Coverage

Coverage for immunotherapy is determined according to individual or group customer benefits. The following guidelines should be used to report antigen or venom immunotherapy.

  • Codes 95144-95165 in conjunction with 95115, 95117, or 95120-95134 as appropriate, should be used to report antigen or venom when total immunotherapy - including preparation, provision, and injection is performed.

  • Codes 95144-95165 should be used to report only the preparation and provision of an antigen or venom by a doctor who may or may not be providing the actual immunotherapy injection.

    NOTE:
    A multiplier can be used with codes 95144-95165. The reporting of a multiplier is representative of the number of doses prepared and provided, not the number of vials.


  • Codes 95115, 95117 should be used to report allergy injection only.

Stinging insect antigen (i.e. whole body antigen) immunotherapy (95170) is not covered. However, stinging insect venom is covered under codes 95145-95149.

If the doctor reports rapid desensitization, report the charge under code 95180 (with the appropriate multiplier for the number of hours).

Sublingual immunotherapy is a specific type of allergy immunotherapy administered by the sublingual route (i.e., under the tongue). Sublingual immunotherapy is considered experimental/investigational and, therefore, it is not covered. Scientific evidence does not demonstrate the safety and efficacy of sublingual immunotherapy. A participating, preferred, or network provider can bill the member for the denied service.

Description

Immunotherapy consists of the administration of slowly increasing quantities of antigen over a period of months, which is followed by a degree of tolerance to the antigen (as is evidenced by the markedly higher doses that can be given) and the decline in the symptoms and medication requirements.


NOTE:
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.

Procedure Codes

951159511795120951259513095131
951329513395134951449514595146
951479514895149951659517095180

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

PRN References

05/1994, Allergy immunotherapy billing clarified
01/1995, Allergy immunothearpy and office visits
03/1995, Allergy immunotherapy
12/1998, Sublingual allergy immunotherapy

References

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Table Attachment

Text Attachment

Procedure Code Attachment


Glossary

TermDescription
Allergen

Any substance that causes manifestations of allergy.
Allergy

An acquired hypersensitivity to a substance (allergen) that does not normally cause a reaction.
Allpyral

Alum-precipitated, pyridine-extracted pollen extracts.
Anaphylaxis

A manifestation of immediate hypersensitivity in which exposure of a sensitized individual to a specific antigen results in life-threatening respiratory distress.
Antibodies

A protein substance developed in response to and interacting specifically with an antigen. This antigen-antibody reaction forms the basis of immunity.
Antigen

A substance that induces the formation of antibodies which interacts specifically with it. This antigen-antibody reaction forms the basis for immunity.
Desensitization

Prevention of anaphylaxis. Usually attained by administering repeated doses of the desensitizing substance too small to cause anaphylaxis.
Emulsion

A mixture of two liquids not mutually soluble.
Extract

A pharmaceutical preparation obtained by dissolving the active constituents of a drug with a suitable medium, evaporating the solvent, and adjusting to prescribed standards.
Hyposensitive

Having reduced ability to respond to stimuli.
Immunization

Becoming immune or the process of rendering a patient immune (protected from a disease).
Immunotherapy

The production or enhancement of immunity. (Allergy shots, hyposensitization, desensitization).
Pollens

The mass of microspores (male fertilizing elements) of flowering plants.
Preparation

A compound or mixture made according to a formula.
Therapy

Treatment of a disease or pathological condition.
Vaccination

Inoculation with any vaccine to establish resistance to a specific infectious disease.
Vaccine

A suspension of infectious agents or some part of them, given for the purpose of establishing resistance to an infectious disease.
Venom

A poison excreted by some animals, such as insects or snakes and transmitted by bites or stings.




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.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.