Currentpriority healthPolicy 103

Allergy Injections / Immunotherapy

Defines coding, billing, place-of-service, documentation, and reimbursement rules for allergy testing and immunotherapy services provided to Priority Health members.

Policy Summary

Payerpriority health

PolicyAllergy Injections / Immunotherapy

Policy CodePolicy 103

Change TypeMaterial updates to coding and annual unit limits

Effective DateSep 1, 2021

Next Review DateOct 1, 2025

Key ActionObtain a Pre‑Service Organization Determination (PSOD) when Medicare indications do not meet NCD/LCD or specific medical policy and check authorization requirements in the Provider Manual.

SourceLink

POLICY UPDATE CHANGES

Allergy studies for percutaneous and intradermal tests (CPT 95004, 95024, 95027) should not exceed 120 units per year regardless of rendering/administering provider.

CPT 95115 and/or 95117 are payable one to three injections per week; any combination exceeding three injections per week will be denied.

CPT 95165 should not exceed 120 units per year.

120max percutaneous/intradermal units

120max CPT 95165 units

1-3/wkpayable 95115/95117 injections

12 momax antigen supply

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Coverage Criteria and Billing Rules

Coverage stance and criteria

Billing and reimbursement rules, medical necessity and documentation requirements for allergy testing and immunotherapy services.

Services are covered when billing, coding, and documentation requirements below are met and medical necessity is supported in the medical record.

Coding and unit limits

Percutaneous and intracutaneous (intradermal) tests are reported with CPT 95004 or 95024; sequential and incremental tests with 95017, 95018, or 95027.
A unit identifies each different allergen or different dilutions of the same allergen; report the number of tests per antigen on the claim and one unit for each test performed for interpretation.
Allergy studies for percutaneous and intradermal tests (CPT 95004, 95024, 95027) should not exceed 120 units per year regardless of rendering/administering provider.
Preparation and provision of allergen immunotherapy for single or multiple antigen extract(s) is reported with CPT 95165; CPT 95165 should not exceed 120 units per year.
Preparation and provision of single dose antigens are reported with CPT 95144–95170; units reflect number of doses supplied and reimbursement is based on a single dose when code description specifies single dose.
Professional services for injection of antigen are reported with CPT 95115–95117; these codes do not include supply of antigen, are reimbursed only in an office setting (POS 11), and CPT 96372 should not be coded for allergy-related injections.
CPT 95115 or 95117 are reported with one unit per date of service; both codes are not payable on the same date of service; CPT 95115 and/or 95117 are payable one to three injections per week — any combination exceeding three injections per week will be denied.
In alignment with CMS, a reasonable supply of antigens should not exceed 12 months for a patient.
In vitro testing is not payable when a skin test is also performed for the same antigen (exceptions: latex sensitivity, Hymenoptera, and nut/peanut); in vitro testing must be supported as a substitute for skin testing and, effective Nov 11, 2024, is limited to 30 allergens per 12‑month period.

Place of service and who may perform services

Codes 95144 and 95145–95170 are payable in office and hospital outpatient settings (POS 19 and 22); 95145–95170 may also be payable in a skilled nursing facility (POS 31) if a physician is present.
Administration may be performed by the physician or those properly trained, including the member if under physician supervision; administration services performed by the member are not billable.

Medical necessity and frequency

Retesting with the same antigen(s) should rarely be necessary within a three-year period; claims for retesting within three years must include documentation of medical necessity.
Allergy testing and allergy immunotherapy are not performed on the same date of service based on standard medical practice and should not be coded on the same date of service.
Single allergy tests should not be coded on the same date as sequential and incremental tests; only one test is reimbursed if the same dilution of the same allergen(s) are tested.

Documentation requirements (must be in the medical record)

Documentation must support medical necessity and the accurate CPT coding and units billed.
Records should include: the allergy test performed and its interpretation; all reactions and complications; testing and plan of treatment including dosage regimen; elements of medical and immunological history; progress notes during course of disease, treatment length, and deviations from the treatment plan or frequency; and retention of allergy tests per legal and facility requirements.
When antigens are prepared by a physician (MD or DO) reimbursement requires that the physician exam result in a plan of treatment defining the dosage regimen and documentation that antigens are administered according to that plan.

Billing rules and claim submission notes

Allergy and immunotherapy services coded incorrectly will be denied or subject to overpayment recoupment.
Allergy services and Evaluation and Management (E/M) services should not be coded for the same date of service unless documentation supports a significant, separately identifiable service; append appropriate modifiers to the original claim submission.
Allergy testing is considered integral to rapid desensitization kits (CPT 95180) and testing and kits are not reported or reimbursed separately.

Pre-service determination / authorization

For Medicare indications that do not meet an NCD, local LCD, or a specific medical policy, a Pre-Service Organization Determination (PSOD) is required; authorization may be required for services and should be checked in the Provider Manual.

Relevant CPT Codes, Limits, and Coding Rules

Relevant CPT codes and groupsCPT

95004	Percutaneous allergy test
95024	Intracutaneous (intradermal) allergy test
95017	Sequential and incremental tests
95018	Sequential and incremental tests
95027	Sequential and incremental tests
95115	Professional services for injection of antigen (component)
95117	Professional services for injection of antigen (component)
95120-95134	Allergy immunotherapy services (professional and provision of extract)
95144-95170	Preparation and provision of single dose antigen
95165	Preparation and provision of allergen immunotherapy for single or multiple antigen extract(s)

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Professional injection administration (component) codesCPT

95115	Professional services for injection of antigen (component)
95117	Professional services for injection of antigen (component)

Preparation/provision of antigen codesCPT

95144-95170	Preparation and provision of single dose antigen
95165	Preparation and provision of allergen immunotherapy for single or multiple antigen extract(s)

Allergy testing codesCPT

95004	Percutaneous allergy test
95024	Intracutaneous (intradermal) allergy test
95017	Sequential and incremental tests
95018	Sequential and incremental tests
95027	Sequential and incremental tests

Immunotherapy service range codesCPT

95120-95134	Allergy immunotherapy services (professional and provision of extract)
95180	Rapid desensitization kits (allergy testing integral)

Max skin test units per year

LimitPercutaneous and intradermal (intracutaneous) allergy studies (CPT 95004, 95024, 95027) are limited to 120 units per 12-month period.

Unit definitionA unit identifies each different allergen or different dilutions of the same allergen.

Provider aggregationThe 120-unit annual cap applies regardless of rendering or administering provider.

Max CPT 95165 units per year

LimitCPT 95165 (preparation and provision of single or multiple antigen extracts) should not exceed 120 units per 12-month period.

Service scopeIncludes preparation of non-venom antigens and the provision of allergen immunotherapy extracts.

Prior Authorization and Provider Requirements

Prior Authorization

Complete PSOD (Pre‑Service Organization Determination) for Medicare indications

For Medicare indications that do not meet an NCD, local LCD, or specific medical policy, complete a Pre‑Service Organization Determination (PSOD) before providing the service; check the Provider Manual for details on when authorization is required and how to submit the PSOD.

PSOD is required for Medicare indications not meeting NCD/LCD or specific medical policy.
Authorization may be required depending on place of service and should be verified in the Provider Manual.

Key Definitions

Allergen immunotherapy definition

DefinitionAllergen immunotherapy (desensitization or hypo-sensitization) is a medical treatment that exposes patients to small amounts of allergens to change or improve their immune system response to those allergens.

PurposeIntended to modify the immune response to specific allergens over time.

Alternate namesAlso known as desensitization or hypo-sensitization.