NC Medicaid Allergy Immunotherapy
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Defines Medicaid coverage, eligibility, limitations, and clinical criteria for allergy immunotherapy and rapid desensitization for NC Medicaid beneficiaries and providers.
Definitions were added for the terms Rapid Desensitization and Hymenoptera Sensitivity.
Unit limitations for several CPT codes updated (e.g., 95180 changed from 12 to 6 units per date of service; multiple preparation codes changed to 10 units per date of service).
Clarified that CPT code 95165 reimbursement is based on mL (changed from cc) and reflects the multi-dose vial content; limits apply (180 units per 365 days).
Coverage and Medical Necessity Criteria
General Coverage Criteria
Covered when ALL of the following are met
From Section 3.1
Specific Criteria for Allergy Immunotherapy
Covered when ALL of the following are met
From Section 3.2.1
Rapid Desensitization Coverage
Covered when ANY of the following are present
From Section 3.2.2
Not Medically Necessary / Non-covered Conditions
Not covered when ANY of the following apply:
From Section 4.1
From Section 4.2.1
From Section 4.2.1
From Sections 4.2.1 and Attachment A
From Section 5.4
From Section 7.2
Allergy immunotherapy is not covered for the conditions listed in the policy. Specifically, Medicaid does not cover immunotherapy for intrinsic (non-allergic) asthma, food allergy, angioedema, chronic urticaria, migraine headaches, or non-allergic vasomotor rhinitis. In addition, immunotherapy directed at certain antigens is excluded (for example: newsprint, tobacco smoke, dandelion, orris root, phenol, formalin, alcohol, sugar, yeast, grain mill dust, pyrethrum, marigold, soybean dust, honeysuckle, wool, fiberglass, green tea, and chalk).
Allergen-proof supplies are not covered. This includes items such as mattresses, mattress casings, pillows, pillow casings, and other commonly used environmental control supplies. The policy states these items may be used for non-medical purposes, can be personal convenience items, and are not considered medically necessary for treatment.
Procedure codes that describe the combined supply of antigen and the allergy injection when provided during a single encounter will not be covered. The policy requires that the supply (preparation) of antigen(s) and the administration of antigen(s) be billed separately using two different CPT codes; combined-supply codes listed in Attachment A are non-covered.
The policy explains that codes describing the complete combined service (supply plus injection) are non-covered and instructs providers to bill antigen preparation and administration on separate lines. See Attachment A Section C for the list of non-covered combined-supply codes; the policy reiterates that the supply (preparation) of antigen(s) and the administration of antigen(s) must be reported using two distinct CPT codes.
For CPT code 95165, a billable unit dose is defined as a 1 mL (cubic centimeter) aliquot. The policy further clarifies that a provider may not bill for more than 10 doses per 10 mL vial (this limit applies to both venom and non-venom antigen codes).
Services are not covered when the beneficiary does not meet Medicaid eligibility (Section 2.0) or the coverage criteria in Section 3.0, when the procedure duplicates another provider's service, or when the procedure is experimental, investigational, or part of a clinical trial.
Restating the policy exclusions: allergy immunotherapy is not medically necessary for the listed conditions (intrinsic non‑allergic asthma, food allergy, angioedema, chronic urticaria, migraine headaches, non‑allergic vasomotor rhinitis) and is not covered when the antigen being treated is one of the explicitly listed non‑covered antigens.
Continuation of immunotherapy beyond two years is not covered when there is no documented clinical benefit. The policy specifies this includes situations where the beneficiary does not experience a noticeable decrease in symptoms, does not demonstrate increased tolerance to the offending allergen, does not reduce medication use, or otherwise lacks documented clinical benefit.
CPT/HCPCS Coding and Unit Limit Rules
| No codes listed |
| 95120 | Non-covered combined supply + injection code list includes 95120,95121,95122,95123,95124,95125,95130,95131,95132,95133,95134 |
| No codes listed |
| 95180 | Allergy treatments (rapid desensitization) - must be billed as one hour equals one unit; Testing Limitations = 6 units per date of service |
| 95144 | Preparation of antigen(s) - Testing Limitations = 10 units per date of service |
| 95145 | Preparation of antigen(s) - Testing Limitations = 10 units per date of service |
| 95146 | Preparation of antigen(s) - Testing Limitations = 10 units per date of service |
| 95147 | Preparation of antigen(s) - Testing Limitations = 10 units per date of service |
| 95148 | Preparation of antigen(s) - Testing Limitations = 10 units per date of service |
| 95149 | Preparation of antigen(s) - Testing Limitations = 10 units per date of service |
| 95165 | Preparation/supervision of build-up and maintenance concentrate vial - billable unit defined as 1 mL aliquot; Testing Limitations = 180 units per 365 days; provider may not bill for more than 10 doses per 10 mL vial |
| 95170 | Preparation of antigen(s) - Testing Limitations = 10 units per date of service |
| 95120 | Non-covered code representative of combined supply + injection; list includes 95120-95125 and 95130-95134 (combined supply/injection codes are not covered) |
| 95115 | Administration of antigen(s) by injection — one injection on same day = one unit |
| 95117 | Administration of antigen(s) by injection — two or more injections on same day = one unit |
| 95180 | Allergy treatment — rapid desensitization billed as one hour equals one unit |
| 95165 | Preparation and provision of build-up and maintenance concentrate vial; billable unit dose defined as 1 mL aliquot; provider may not bill for more than 10 doses per 10 mL vial; limit 180 units per 365 days |
Provider Requirements, Prior Authorization, and Documentation
Verify prior approval per Section 5; EPSDT does not waive approvals
Prior approval may be required as described in Section 5; EPSDT does not eliminate prior approval requirements for beneficiaries under 21 — verify prior approval rules in Section 5 and EPSDT guidance before providing services.
No prior approval required for allergy immunotherapy
Medicaid shall not require prior approval for Allergy Immunotherapy; providers may proceed with billing without obtaining prior approval for allergy immunotherapy services.
Comply with NCTracks, bulletins, fee schedules, and clinical coverage policies
Follow NCTracks, Medicaid bulletins, fee schedules, and NC Medicaid clinical coverage policies for coverage and reimbursement; use payer/PTP processes for any required authorizations as directed in those resources.
No other prior authorization specified — follow CPT/unit rules
The policy does not state an additional prior authorization requirement in Attachment A or billing sections; providers must use the specified CPT codes and follow the unit/billing rules in Attachment A when submitting claims.
Attempt conservative therapy and identify allergens before immunotherapy
Initiate immunotherapy only after hypersensitivity cannot be managed with medications or allergen avoidance and after triggering allergens have been identified by appropriate skin or blood testing per policy 1N-1.
- Document that medications/allergen avoidance were tried and found insufficient.
- Document allergen identification via appropriate testing per policy 1N-1.
Do not continue treatment beyond 2 years without documented benefit
Do not continue allergy immunotherapy beyond two years without documented clinical benefit; discontinue if there is no symptom decrease, no increased tolerance, no reduction in medication use, or no documented clinical benefit.
- Document ongoing symptom change, tolerance, medication use, and other clinical benefit before authorizing continued treatment >2 years.
Verify eligibility each visit and document EPSDT justification for <21
Verify Medicaid eligibility at each encounter; for beneficiaries under 21, include EPSDT documentation to justify care that exceeds policy limits when applicable.
- Confirm and document beneficiary eligibility prior to each service.
- For <21, include EPSDT justification when requesting services beyond standard limits.
Document medical necessity, diagnostics, reactions, effectiveness, and vial/dose details
Maintain health record documentation that confirms medical necessity, shows indications determined by appropriate diagnostic procedures, records injection reactions, documents treatment effectiveness, and reflects the number of vials/doses prepared and the injection schedule.
- Include diagnostic test results per policy 1N-1 demonstrating identified allergens.
- Record injection reactions and continuing evaluation of effectiveness.
- Document number of vials and doses prepared and injection schedule.
Bill office visit with injection only if separately identifiable; use Modifier 25
An office visit must not be billed on the same day as an allergy injection unless the visit represents a significant, separately identifiable service; append Modifier 25 to the office visit code when appropriate.
- Do not bill routine injection follow-up as a separate office visit without a separately identifiable service documented.
Use highest specificity ICD-10 and CPT/HCPCS codes (or appropriate unlisted codes)
Report ICD-10-CM/PCS and CPT/HCPCS to the highest level of specificity using current editions; if no specific code exists, report the appropriate unlisted code with required supporting documentation.
Bill antigen preparation and administration separately using distinct CPTs
Report separate CPT codes for administration, antigen preparation, and rapid desensitization; bill antigen supply/preparation and administration using distinct CPT codes and do not combine supply and administration in one code.
- Preparation (e.g., 95165) and administration must be billed separately using two different CPT codes.
- Follow Attachment A CPT listings for correct code selection.
Apply applicable modifier guidelines when reporting services
Follow applicable modifier guidelines when reporting services as directed in Attachment A and the Unlisted Procedure or Service section.
Denial if beneficiary lacks eligibility, criteria, or if service duplicates/experimental
Services will be denied when the beneficiary lacks eligibility, does not meet coverage criteria, the service duplicates another provider's service, or the service is experimental, investigational, or part of a clinical trial.
Denial risk: failure to meet eligibility or coverage criteria or duplicate billing
Claims may be denied when the beneficiary fails eligibility or coverage criteria, or when duplicate services are billed by another provider.
Do not treat/bill for explicitly non-covered indications or listed non-covered antigens
Allergy immunotherapy will be denied when the indication is intrinsic (non-allergic) asthma, food allergy, angioedema, chronic urticaria, migraine headaches, non-allergic vasomotor rhinitis, or when the antigen is one of the listed non-covered antigens.
- Do not submit claims for the explicitly non-covered indications or listed antigens.
Do not bill for allergen-proof supplies or combined supply+injection codes
Do not submit claims for allergen-proof supplies (mattresses, casings, pillows, etc.) and do not bill combined supply+injection procedure codes; these items and combined-code services are not covered.
- Supply items are considered personal convenience items and are not covered.
- Combined supply+injection CPTs listed in Attachment A are non-covered and should not be billed.
Do not bill combined supply+injection with a single CPT — bill supply and administration separately
Billing the combined supply of antigen and the injection using a single CPT code that describes the complete service will not be covered; supply and administration must be billed separately per Attachment A.
- Use two different CPT codes — one for preparation/supply and one for administration.
Do not bill more than 10 doses per 10 mL vial for CPT 95165
Do not bill CPT 95165 for more than 10 doses per 10 mL vial; unit dose is defined as a 1 mL aliquot and the provider may not bill more than 10 doses per 10 mL vial (applies to venom and non-venom antigen codes).
- A billable unit dose for 95165 is defined as 1 mL aliquot; do not bill >10 doses per 10 mL vial.
Definitions and Terminology
Background and Clinical Context
Background: Allergy immunotherapy (desensitization or allergy shots) reduces sensitivity to identified allergens by gradual dose escalation to a maintenance dose and may be continued for years. Rapid desensitization is a faster build-up approach that allows several months of build-up to be completed in a single day. Covered indications include clinically significant allergic conditions when allergens are identified by appropriate testing and symptoms cannot be controlled by medications or avoidance.
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