Allergen Immunotherapy CPT CODES - 95115 - 95180 and valid DX codes

CMS National Coverage Determinations for allergen immunotherapy include the provision that only injected antigens are covered by Medicare. Non-injected antigens and professional services associated with preparation of non-injected antigens must not be reported to Medicare for payment as injected antigens.

For injected antigens, Medicare will allow coverage for under the following conditions:

• Diagnosed hypersensitivity to a substance indicated by the appropriate ICD-9-CM code(s) listed in this policy.
• Hypersensitivity that cannot be managed by a medication or avoidance.
• The allergens should be prepared for the patient individually
• The allergen content should be based on appropriate skin testing, or appropriate in vitro testing.

Compliance with the provisions in this policy is subject to monitoring by postpayment data analysis and subsequent medical review.

Limitations:

Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

• Safe and effective.
• Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
• Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
• Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
• Furnished in a setting appropriate to the patient’s medical needs and condition.
• Ordered and furnished by qualified personnel.
• One that meets, but does not exceed, the patient’s medical need.
• At least as beneficial as an existing and available medically appropriate alternative.

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

12X, 13X, 18X, 21X, 22X, 23X, 71X, 83X, 85X

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual Publication 100-04, Claims Processing Manual, for further guidance.

0949

CPT/HCPCS Codes

	Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
95115©	Immunotherapy, one injection
95117©	Immunotherapy injections
95144©	Antigen therapy services
95145©	Antigen therapy services
95146©	Antigen therapy services
95147©	Antigen therapy services
95148©	Antigen therapy services
95149©	Antigen therapy services
95165©	Antigen therapy services
95180©	Rapid desensitization

ICD-9-CM Codes that Support Medical Necessity

The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 95115, 95117, 95144, 95145, 95146, 95147, 95148, 95149, 95165 and 95180:

Covered for:

372.05	Acute atopic conjunctivitis
372.14	Other chronic allergic conjunctivitis
381.00–381.06	Acute nonsuppurative (allergic) otitis media
471.0	Polyp of nasal cavity
471.8	Other polyp of sinus
473.0–473.3	Chronic sinusitis
477.0–477.2	Allergic rhinitis
477.8–477.9	Allergic rhinitis
493.00	Extrinsic asthma unspecified
493.10–493.11	Intrinsic asthma
493.20	Chronic obstructive asthma unspecified
493.90–493.91	Asthma unspecified
691.8	Other atopic dermatitis and related conditions
692.9	Contact dermatitis and other eczema, unspecified cause
693.1	Dermatitis due to food taken internally
989.5	Toxic effect of venom
995.0	Other anaphylactic shock not elsewhere classified
995.21–995.23	Unspecified adverse effect of drug, medicinal and biological substance
995.27	Other drug allergy
995.29	Unspecified adverse effect of other drug, medicinal and biological substance
995.3	Allergy unspecified not elsewhere classified
V14.0–V14.3	Personal history of allergy to medicinal agents

Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

Diagnoses that Support Medical Necessity

N/A

ICD-9-CM Codes that DO NOT Support Medical Necessity

N/A

Diagnoses that DO NOT Support Medical Necessity

All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.

Documentation Requirements

Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.

When requesting a written redetermination (formerly appeal), providers must include all relevant documentation with the request.