Clarification in Limitations of Allergen Immunotherapy

Clarification in Limitations of Allergen Immunotherapy

Based on recommendations of network providers, the immunotherapy preparation (CPT 95165) benefit has been modified to allow 80 units in 6 months. This will facilitate ease of payment for initial preparation of antigen mixture for new patients and is consistent with national guidelines.

Subsequent to the initial preparation claim, Texas Children’s Health Plan anticipates immunotherapy preparation (CPT 95165) maintenance claims consistent with national guidelines.

Billing

Use of CPT code 95165, professional services for the supervision and provision of antigens for allergen immunotherapy in excess of 80 units every 6 months, will be denied.

Claims appeals

Instances in which units over 80 are billed and denied will need to be appealed with clinical documentation.  Documentation must include:

  • Proof avoidance or pharmacologic therapy has been unable to control symptoms.
  • Information on side effects to pharmacologic therapy if present.
  • Evidence of response to skin or serology testing.
  • Documentation of allergy type if determined to be life threatening (bees, fire ants, wasps, etc.).
  • Confirmation of symptoms of allergic rhinitis after natural exposure to allergen.

This policy is in accordance with the state limitation of 160 units per year.

If you have any questions regarding the claims appeal process, please contact Texas Children’s Health Plan Provider Relations at 832-828-1008.

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