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Medical Policy: 02.01.01
Original Effective Date: April 1995
Reviewed: July 2008
Revised: January 2005
This policy applies to all products unless specific contract
limitations, exclusions or exceptions apply. Please refer to the member's coverage
manual for benefit availability. Managed care guidelines related to referral authorization,
and precertification of inpatient hospitalization, home health, home infusion and
hospice services apply.
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.
Policy:
Allergy Immunotherapy with subcutaneous injections may be considered medically necessary for patients with demonstrated hypersensitivity that cannot be managed by medications or avoidance to the following:
- 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 Desensitization process) may be considered medically necessary for patients with either of the following:
- Insect Sting hypersensitivity
- IgE antibodies to a particular drug that is essential for a condition that cannot be treated effectively with alternate medications
The following allergy immunotherapies are not covered because they are considered investigational:
- 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, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- Use appropriate CPT codes for allergen immunotherapy from the range of 95115 through 95199.
- 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:
- The Medical Policy Reference Manual (MPRM) developed by the Blue Cross Blue Shield Association Health Management Systems, based on Technology Evaluation Center (TEC) criteria.
- 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.
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New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309
*Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.
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.
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