Oct-Nov 00 Part A Bulletin - Medicare

LOCAL AND FOCUSED MEDICAL REVIEW POLICIES
95115: Allergen Immunotherapy (continued)
ICD-9-CM Codes that DO NOT
Support Medical Necessity
N/A
Diagnosis that DO NOT Support
Medical Necessity
N/A
Reasons for Denial
Allergen immunotherapy performed for indications
other than those listed in the “Indications and Limitations
of Coverage and/or Medical Necessity” section of this
policy.
Noncovered ICD-9-CM Code(s)
Any diagnosis codes not listed in the “ICD-9-CM
Codes That Support Medical Necessity” section of this
policy.
Noncovered Diagnosis
N/A
Coding Guidelines
You may choose to use HCPCS code 95115 to report
all allergy therapies provided during a visit, without regard
to the type or number of antigens, or you may report each
of the HCPCS codes in this policy separately.
Documentation Requirements
Medical record documentation maintained by the
treating physician must clearly document the medical
necessity to initiate allergen immunotherapy and the
continued need thereof. The documentation should
include:
• A history and physical that documents the following: a
complete allergic history and physical examination,
correlation of symptoms, occurrence of symptoms,
exposure profile, documentation of allergic
sensitization by accepted means and where attempts at
avoidance have proven unsuccessful (or the
impracticality of avoidance exists), and a copy of the
sensitivity results.
• Progress notes that document physician management
during the course of the allergic disease, anticipated
length of treatment, and explanation of any deviations
from normal treatment frequency.
Utilization Guidelines
N/A
Other Comments
Terms Defined:
Allergen—any substance that indicates a state of, or brings on
manifestations of, allergy.
Allergy—an altered reaction of body tissues to a specific
substance (allergen) which in nonsensitive persons will, in
similar amounts, produce no effect.
Asthma—a reversible obstructive lung disorder characterized
by increased responsiveness of the airways.
Immunotherapy—the production or enhancement of
immunity.
Rhinitis—inflammation of the nasal mucosa.
Sources of Information
American Medical Association. (1996). Allergy
immunotherapy update. cpt Assistant, (6)5, 1-2 and 11.
American Medical Association. (2000). Allergy
immunotherapy – Provision of antigens. cpt Assistant, 10
(4), 4.
Middleton, Jr., E., Reed, C., Ellis, E.F., Adkinson, Jr., N.F.,
Yunginger, J.W., and Busse, W.W. (Eds.). (1998). Allergy
principles and practice. (Vol II). St. Louis: Mosby.
Theodoropoulos, D.S. & Lockey, R.F. (2000). Allergen
immunotherapy: Guidelines, update, and recommendations
of the World Health Organization. Allergy Asthma Proc.
2000, 21(3), 159-166.
Advisory Committee Notes
This policy does not reflect the sole opinion of the
contractor or Contractor Medical Director. Although the final
decision rests with the contractor, this policy was developed in
cooperation with the contractor’s Advisory Committee, which
includes representatives from numerous societies.
Start Date of Comment Period
06/12/2000
Start Date of Notice Period
10/01/2000
Revision History
Revision Number: Original
Start Date of Comment Period: 06/01/2000
Start Date of Notice Period: 10/01/2000
Oct/Nov 2000 Bulletin
Original Effective Date: 11/15/2000 �
40 The Florida Medicare A Bulletin
October/November 2000