New Medical Guidance Provides Insurance Recommendations for Allergen Immunotherapy

The American Academy of Allergy, Asthma & Immunology (AAAAI), the American College of Allergy, Asthma & Immunology (ACAAI), and the American Academy of Otolaryngic Allergy (AAOA) have released a set of guidelines to insurance companies concerning necessary requirements for allergen immunotherapy documentation.¹

Known to be the most widely implemented and effective form of allergen immunotherapy, subcutaneous immunotherapy (SCIT) is commonly referred to as allergy shots and maintains a unique ability to alter a patient’s immune system. By doing this, it diminishes one’s sensitivity to allergens and helps to prevent the emergence of newer allergies and conditions like asthma.

“Burdensome and unreasonable requests for documentation regarding these services threaten the ability of allergists/immunologists and otolaryngologists to administer these therapies,” J. Allen Meadows, MD, ACAAI’s executive director of advocacy and government affairs and the lead author, said in a statement. “They also hinder the ability of patients with allergic conditions to obtain relief.”¹

These new recommendations were formed through a work group that was begun by the ACAAI. They were published in Annals of Allergy, Asthma and Immunology, with the principal aim being to assist payers in the development of a process for claims reviews submitted under the CPT Codes 95115, 95165, and 95117.

Each and every one of the procedures covered by these 3 codes are deemed medically necessary for individuals who have asthma, allergic rhinitis, or atopic dermatitis. However, the paper notes that insurers have increasingly asked for extensive, unnecessary documentation.

“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,” Meadows said in a statement. “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.”

This, it noted, has created major delays in payment—or denial of payment entirely—for valid claims, jeopardizing access to necessary allergen immunotherapy. The latest guidance lays out, for allergy immunotherapy, what the authors view to be either reasonable or unreasonable requests for related documentation.

In reference to CPT 95165, referring to the services for the supervision of preparation and provision of antigens necessary for allergen immunotherapy, the following payer requests for documentation were described as reasonable:

• A response to allergy immunotherapy description and the necessity for continued allergen immunotherapy during the course of routine visits.
• Patients’ identities alongside a short description of clinical indications for allergen immunotherapy.
• The identity of one’s clinician who determined the plan for immunotherapy treatment.
• A small description of a patient’s treatment plan as well as the date on which it was determined.

In claims submitted under 95115 or 95117, the authors and sponsoring societies for these recommendations noted that the following payer requests for documentation are deemed as reasonable:

• The site of one’s injection.
• The administered dose with specifications on dilution, volume, and injection numbers.
• Signature or initials of the individual who administers one’s injection.
• The name, the date of patient’s injection, and their birth date.

When determining what forms of documentation were unnecessary, the AAAAI, the ACAAI, and the AAOA decided that the following documentation was included in such a list and was often unduly burdensome for those providing the information:

• A patient’s fully planned schedule for dosing.
• The date of one’s vial expiration.
• Previous injection histories.
• Credentials of the individual providing the injection administration
• Signature of one’s ordering healthcare professional
• Several different audit requests.
• Specification of subcutaneous administration

References

1. ^{Joint recommendations outline reasonable and unreasonable requests for documentation. ACAAI. November 6, 2024. https://acaai.org/news/new-guidelines-for-insurers-help-patients-receive-necessary-allergen-immunotherapy-treatment/. Date accessed: November 19, 2024.}