June 1, 2019
Provide guidelines for coverage and reimbursement of allergy immunotherapy due to overutilization and abuse.
All Government Programs products included:
- Medicare Advantage Dual Special Needs (HMO SNP)
Allergy Immunotherapy: Allergy (or allergen) immunotherapy or subcutaneous immunotherapy (SCIT) is the repeated administration of specific allergens to an individual with immune globulin E (IgE)--mediated conditions, to provide protection against the allergic symptoms and inflammatory reactions associated with exposure to these allergens.
CPT Code 95165: Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses)
Horizon NJ Health will reimburse the following:
- Injection portion from the applicable rendering provider (CPT 95115-95117)
- Antigen and preparation (CPT 95144-95170)
Up to one hundred and twenty (120) units of CPT code 95165 from a certified provider, per member, for the initial rolling calendar year of treatment
Up to sixty (60) units of CPT code 95165 from a certified provider, per member, for the subsequent rolling year(s) for maintenance therapy
- Horizon will not pay past two (2) years of maintenance therapy without supporting documentation
- Continued maintenance will be contingent upon accepted standards of six to twelve (6-12) month follow-up after the initiation of immunotherapy
- An Evaluation and Management (E/M) service, IF a significant, separately, identifiable service has been performed and reported with the appropriate modifier. (Documentation must be submitted to support the use of the modifier)
Horizon NJ Health shall limit CPT code 95165 in the initial rolling calendar year to one hundred and twenty (120) units. (Days 1-365)
Horizon NJ Health shall limit CPT code 95165 after the initial rolling calendar year to sixty (60) units for maintenance therapy for two (2) years post initial rolling year. (Days 366-1,095)
Horizon NJ Health shall deny ALL claims after the 1,096th day for CPT code 95165.
Horizon NJ Health shall deny any Evaluation and Management (E/M) code billed with allergy immunotherapy that does not include modifier -25. (E/M codes: 99201, 99202, 99203, 99203, 99204, 99205, 99211, 99212, 99213, 99214 and 99215)
Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
- Mandated or legislative required criteria will always supersede.
Cox L, Nelson H, Lockey R, et al. Allergen immunotherapy: a practice parameter third update. J Allergy Clin Immunol 2011; 127:S1.
Calderón MA, Cox L, Casale TB, et al. Multiple-allergen and single-allergen immunotherapy strategies in polysensitized patients: looking at the published evidence. J Allergy Clin Immunol 2012; 129:929.
Larenas-Linnemann DE, Gupta P, Mithani S, Ponda P. Survey on immunotherapy practice patterns: dose, dose adjustments, and duration. Ann Allergy Asthma Immunol 2012; 108:373.
Rosman Y, Confino-Cohen R, Goldberg A. Venom Immunotherapy in High-Risk Patients: The Advantage of the Rush Build-Up Protocol. Int Arch Allergy Immunol 2017; 174:45.
Department of Health and Human Services, Medicare Antigen Preparation, 2002
Department of Health and Human Services, Allergen Immunotherapy For Medicare Beneficiaries, 2006