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Medical Policy Changes for Allergy Immunotherapy

Blue Cross and Blue Shield of North Carolina (BCBSNC) revised its corporate medical policy titled “Allergy Immunotherapy/Desensitization” on May 27, 2014, to include limits on the number of units that may be submitted per year. Additionally, a new policy statement was introduced regarding home immunotherapy. BCBSNC will not cover subcutaneous immunotherapy administered in the home setting as of July 29, 2014.

 

Why?

A review of submitted claims for allergy immunotherapy (CPT code 95165) revealed a dramatic increase in units billed. Upon further investigation, BCBSNC discovered that some doctors are providing immunotherapy extracts for injection to their patients. The patients, or their caregivers, are then instructed on how to administer injections at home. Immunotherapy is generally a safe and effective treatment; however, there is a risk of severe anaphylactic reactions. All published professional guidelines strongly suggest that immunotherapy should be administered in the prescribing clinician’s office with emergency equipment available and staff who can recognize and treat anaphylaxis should it occur.

 

When?

The revised medical policy was published on May 27, 2014, and serves as formal 60-day notice of the changes that will be effective on July 29, 2014.

 

Approved Coverage for Allergy Immunotherapy

Allergy immunotherapy, also called allergy shots, is a treatment for patients with severe allergies, who cannot avoid the offending allergen (like dust mites or pollen) and for whom traditional medical therapy has not been effective. The dosages start low and increase incrementally until the patient becomes tolerant of the allergen. This is referred to as the build-up or escalation phase. The patient then receives maintenance doses. After the optimum maintenance dose is achieved, the interval between injections may range between two and six weeks with immunotherapy being administered continuously for several years, if deemed medically necessary for the patient in question. BCBSNC will continue to cover allergy shots given in the provider’s office; however, unit limitations will be set at 180 units for the escalation period and 120 units per year thereafter, beginning July 29, 2014.

 

If you have any questions, please contact the Provider Blue LineSM at 1-800-214-4844.