New Guidelines for Insurers Help Patients Receive Necessary Allergen Immunotherapy Treatment

Newswise — ARLINGTON HEIGHTS, Ill. (Nov. 6, 2024) – Newly-published guidance from the American College of Allergy, Asthma & Immunology (ACAAI), the American Academy of Allergy, Asthma & Immunology (AAAAI) and the American Academy of Otolaryngic Allergy (AAOA) provides useful recommendations to insurance companies regarding appropriate documentation requirements for allergen immunotherapy. The guidance was developed by a work group initiated by ACAAI and is published in Annals of Allergy, Asthma and Immunology, ACAAI’s scientific journal.

“Burdensome and unreasonable requests for documentation regarding these services threaten the ability of allergists/immunologists and otolaryngologists to administer these therapies,” says allergist J. Allen Meadows, MD, ACAAI Executive Director of Advocacy and Government Affairs, and lead author on the paper. “They also hinder the ability of patients with allergic conditions to obtain relief.”

Allergen immunotherapy in the form of allergy shots, also known as subcutaneous immunotherapy (SCIT), is the most used and most effective form of allergy immunotherapy. It is the only treatment that changes the immune system, making it possible to reduce the impact of allergens on the body and prevent the development of new allergies and asthma.

The goal of the recommendations is to assist payers in developing a process for reviewing claims submitted under CPT Codes 95165, 95115, and 95117 in a way that is “efficient, fair and not unduly burdensome.”

According to the paper,  all the procedures covered by the three codes are medically necessary for patients suffering from allergic rhinitis, asthma, or atopic dermatitis. The paper also states, “In recent years, payers have increasingly demanded multiple, detailed documentation that is both highly burdensome to the physician and generally unnecessary.” The demands have resulted in significantly delayed payment – or worse, non-payment for entirely appropriate procedures. These burdensome requirements threaten the ability of patients to receive necessary allergen immunotherapy treatment.

The guidance lays out what the authors see as reasonable and unreasonable requests for documentation for allergy immunotherapy services.

CPT 95165 describes the professional services for the supervision of preparation and provision of antigens for allergen immunotherapy. The authors and the societies they represent believe that the following requests by the payer for documentation are reasonable:

1. The identity of the physician who established the treatment plan.
2. The identity of the patient and a short description of the clinical indications for allergen immunotherapy.
3. A brief description of the treatment plan and the date on which it was formulated; and
4. A description of the response to allergy immunotherapy and the need for continued allergen immunotherapy at routine visits.

The authors and sponsoring societies state that the following requests by the payer for documentation are reasonable to support a claim submitted under 95115 or 95117:

1. The date of the injection, the name, and birth date of the patient.
2. The dose administered, specifying volume, dilution, and number of injections.
3. The site(s) of the injection, e.g. right arm.
4. The initials or signature of the person administering the injection (whether actual or electronically).

The ACAAI, AAAAI and AAOA agree that the following documentation is unnecessary, and that the provision of this information is often unduly burdensome:

1. Date of vial expiration/”best use by”
2. Full planned dosing schedule
3. Specification of subcutaneous administration
4. Signature of ordering healthcare professional
5. Credentials of the person administering the injection
6. A history of previous injections; and
7. Multiple audit requests

The three organizations recognize that it is reasonable for insurance companies and other payers to request documentation to demonstrate that a claim submitted under CPT Code 95165, 95115, or 95117 is for a medically necessary service that has been performed and has been properly coded.  At the same time, the authors stress that demands for several kinds of additional documentation that have been made by some insurers are unnecessary.

According to Dr. Meadows, “At the end of the day, not only are physicians hamstrung by excessive demands from insurance companies, but patients may not get the care they need. Patients who suffer from allergic diseases such as allergic rhinitis, asthma and atopic dermatitis rely on consistent delivery of allergen immunotherapy to keep their symptoms under control. When they can’t get it, their quality of life is compromised.”

About ACAAI

ACAAI is a professional medical organization of more than 6,000 allergists-immunologists and allied health professionals, headquartered in Arlington Heights, Ill. The College fosters a culture of collaboration and congeniality in which its members work together and with others toward the common goals of patient care, education, advocacy, and research. ACAAI allergists are board-certified physicians trained to diagnose allergies and asthma, administer immunotherapy, and provide patients with the best treatment outcomes. For more information and to find relief, visit AllergyandAsthmaRelief.org. Join us on Facebook, Pinterest, Instagram  and Twitter/X.