CAM 009

Allergy Immunotherapy

Category:Medicine   Last Reviewed:October 2018
Department(s):Medical Affairs   Next Review:October 2019
Original Date:October 2000    

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.

Related Policy 
CAM 051 Allergy Testing

Policy:
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 30 doses in a 12-week period. (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.

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 NON-COVERED:

  • 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 non-medical purposes and are NOT CONSIDERED MEDICALLY NECESSARY for the treatment of illness. 

Subcutaneous immunotherapy performed in the home setting is considered INVESTIGATIONAL. 

References:

  1. Beyer K, Teuber SS. Food allergy diagnostics: Scientific and unproven procedures. Curr Opin Allergy Clin Immunol. 2005;5(3):261-266.
  2. 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.
  3. Reider N. Sublingual immunotherapy for allergic rhinoconjunctivitis--the seeming and the real. Int Arch Allergy Immunol. 2005;137(3):181-186.
  4. 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.
  5. 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.
  6. 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 and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines. 

"Current Procedural Terminology© American Medical Association.  All Rights Reserved"  

History From 2013 Forward     

10/01/2018 

Annual review, no change to policy intent. 

08/29/2018 

Interim review, editing for clarity of dosages allowed in a 12 week period. No change to policy intent. 

10/02/2017 

Annual review, no change to policy intent. 

10/11/2016 

Annual review, no change to policy intent. 

10/08/2015 

Updating policy verbiage to indicate: Subcutaneous immunotherapy performed in the home setting is considered INVESTIGATIONAL. Also changing the policy verbiage to include and/or statements regarding insect stings and other symptoms. Adding and/or statement regarding avoidance and/or pharmacologic therapy. 

5/19/2015 

Increasing the number of units allowable per 12 weeks from 24 to 30.

10/07/2014

Annual review. No change to policy intent. Verbiage added related to the number of antigens vs. the number of doses: (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). 

10/30/2013

Added Related Policy Section. Clarify verbiage in policy section from Allergy testing to Immunotherapy.


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