Allergy Immunotherapy

Medical Policy: 02.01.01 
Original Effective Date: April 1995 
Reviewed: September 2011 
Revised: September 2011 

Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.

Description: 

Allergic or hypersensitivity disorders can manifest themselves as generalized systemic reactions as well as localized reactions in any organ system of the body.  Numerous agents, e.g., pollen, mold, dust mites, animal dander, insect stings, foods or drugs, may precipitate allergic or hypersensitive reactions.  For details on coverage of allergy testing services, see Policy 02.01.02, Allergy Testing.

The management of an allergic patient should include a comprehensive history, physical examination and should include confirming the cause of allergies.  Once the agent is identified, treatment is provided by avoidance, medication or immunotherapy.

Immunotherapy involves regular injections of offending allergens which are not readily avoidable.  The treatment is provided over a period of months to years, with a goal of reducing symptoms.  The exact mechanism of action is not known but may involve an increase in allergen specific IgG antibodies, a decrease in IgE synthesis and alteration in T-lymphocyte activity. 

The treatment plan varies but generally begins with low doses of allergens with gradually increasing doses injected once or twice a week as immunity to the antigen develops.  After the maintenance dose is achieved, the interval between injections may range between two to six weeks.  Immunotherapy may continue for several years.

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Prior Approval: 

Not applicable

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Policy: 

• Allergic asthma (Extrinsic asthma)
• Hymenoptera (bees, hornets, wasps, fire ants) sensitivity
• Aeroallergen exposure to perennial allergens including dust mites, mold or animal dander 
• Perennial rhinitis
• Seasonal allergic rhinitis or conjunctivitis
• Pollens such as ragweed, grass or trees 

Allergy therapy with Rapid Desensitization (also known as Rush or Cluster Desensitization process) may be considered medically necessary for patients with either of the following:

• Insect Sting hypersensitivity 
• Drug hypersensitivity that is essential for a condition that cannot be treated effectively with alternative medications
• Food antigens such as milk and legumes (i.e., peanuts)

• Provocative and neutralization therapy for food allergies, using intradermal and subcutaneous routes
• Sublingual provocation or neutralization 
• Urine auto-injections; (autogenous urine immunization)
• Repository emulsion therapy
• Rinkel, also known as serial endpoint dilution titration therapy for ragweed pollen hay fever
• Any treatment related to the Nambudripad's Allergy Elimination Technique (NAET)
• Rhino phototherapy involves the use of a light emitting device inserted into the nose to expose sinus and nasal tissues to UV and visible light.  

Allergen-proof supplies, such as mattresses, pillows, and casings, etc., are considered personal convenience items and are not covered.

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Procedure Codes and Billing Guidelines: 

• To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
• 95115 Professional services for allergen immunotherapy not including provision of allergenic extracts; 2 or more injections
• 95117 Professional services for allergen immunotherapy not including provision of allergenic extracts; 2 or more injections
• 95120 Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; single injection
• 95125 Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; 2 or more injections
• 95130 Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; single stinging insect venom
• 95131 Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; 2 stinging insect venoms 
• 95132 Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; 3 stinging insect venoms
• 95133 Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; 4 stinging insect venoms
• 95134 Professional services for allergen immunotherapy in prescribing physicians office or institution, 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 dose vial(s) (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; whole body extract of biting insect or other arthropod (specify number of doses)
• 95180 Rapid desensitization procedure, each hour (eg, insulin, penicillin, equine serum)             
• To report sublingual antigens use CPT code 95199.
• Use CPT 0168T for Rhinophototherapy, intranasal application o ultraviolet and visible light, bilateral 

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Selected References: 

• TEC assessment by the Blue Cross Blue Shield Association, Serial endpoint testing for the diagnosis and treatment of allergic disorders. TEC Bulletin April 5, 2002; volume 19#1:22-24.
• Vourdas D, Syrigou E, Potamianou P, Carat F, Batard T, Andre C, Papageorgiou PS. Double-blind, placebo-controlled evaluation of sublingual immunotherapy with standardized olive pollen extract in pediatric patients with allergic rhino-conjunctivitis and mild asthma due to olive pollen sensitization. Allergy 1998;53:662-672.
• Munoz-Lopez F. Editorial; New administration route in immunotherapy. Allergologia et Immunopathologia 2000; 28(6):295-297.
• Lockey RR, Bousquet J, Malling HJ. WHO position paper on oral (Sublingual) immunotherapy. Annals of Allergy, Asthma and Immunology 1999; vol. 8:423-424.
• Seidenfeld, J, et al. Sublingual Immunotherapy for Adults. TEC Assessment Program Vol. 18, No. 4 June 2003
• American Academy of Allergy, Asthma and Immunology. American College of Allergy, Asthma and Immunology.   Allergen immunotherapy: a practice parameter.  Ann Allergy Asthma Immunol. 2003 Jan; 90(1 Suppl 1): 1-40
• Barrett S, Index of Questionable Treatments; Nambudripad's Allergy Elimination Technique (NAET); www.quackwatch.org; Accessed on the web 12/20/05.
• Cox L; Linnemann D, et al.  Sublingual immunotherapy: a comprehensive review.  J Allergy Clin Immunol 2006 May;117(5):1021-35.
• Varshney P, Jones SM, Scurlock AM et al. A randomized controlled study of peanut oral immunotherapy: clinical desensitization and modulation of the allergic response. J Allergy CLin Immunol. 2011 Mar; 127(3):654-60.
• Jones SM, Pons L, Roberts JL et al. Clinical efficacy and immune regulation with peanut oral immunotherapy. J Allergy Clin Immunol. 2009 Aug; 124(2):292-300, 300.el-97. Epub 2009 Jul 3.
• Shripak JM, Nash SD, Rowley H et al. A randomized, double-blind, placebo-controlled study of milk oral immunotherapy for cow’s milk allergy. J Allergy Clin Immunol. 2008 Dec; 122(6):1154-60. Epub 2008 Oct 25.
• Zapatero L, Alonso E, Fuentes V et al. Oral desensitization in children with cow’s milk allergy. J Investig Allergol Clin Immunol. 2008; 18(5):389-96.  

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Policy History: 

Date                                        Reason                               Action

September 2011                     Annual review                     Policy revised

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Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.