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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.4 Allergy Services : 9.2.4.1 Allergy Immunotherapy

9.2.4.1
Allergen immunotherapy consists of the parenteral administration of allergenic extracts as antigens at periodic intervals, usually on an increasing dosage scale to a dosage which is maintained as maintenance therapy.
Preparation of the allergy vial or extracts is a benefit of Texas Medicaid when preparations are made in accordance with the American Academy of Allergy, Asthma, and Immunology. Claims for preparations should be submitted using the following procedure codes:
 
Administration of the allergy extract may be reimbursed using procedure codes 95115 and 95117.
Rapid desensitization may be reimbursed using procedure code 95180 when submitted with diagnosis code Z516.
Allergen immunotherapy is a benefit for clients who have allergy conditions when the following criteria are met:
Hypersensitivity cannot be managed by avoidance or pharmacologic therapy to control allergic symptoms, or the client has unacceptable side effects with pharmacologic therapy.
The preparation of the allergy vial or extract and the administration of an injection may be reimbursed for the following diagnosis codes:
 
 
9.2.4.1.1
Authorization is not required for immunotherapy services; however, requests for services beyond the established limits of 160 doses per one-year period for procedure code 95165 may be considered for prior authorization with documentation of medical necessity. Documentation must be submitted to the Special Medical Prior Authorization Department and include the following information:
9.2.4.1.2
The quantity billed for the allergy extract preparation procedure must represent the total number of doses to be administered from the vial. If the number of doses is not stated on the claim, a quantity of one is allowed.
Note:
Procedure code 95165 is limited to a total of 160 doses per one-year period, which begins the date the immunotherapy is initiated. Additional doses may be considered for reimbursement through prior authorization with documentation of medical necessity. Procedure code 95165 is limited to no more than ten doses per vial.
When an injection is given from a vial, providers should use an administration-only procedure code (95115 or 95117). Reimbursement for the administration is limited to one per day.
An office visit, clinic visit, or observation room visit is not considered for reimbursement in addition to the fee for the preparation or the administration of the allergy vial or extract unless the additional visit results in a non-allergy-related diagnosis or a re-evaluation of the client’s condition. The following E/M procedure codes may be submitted with modifier 25:
 
Allergen immunotherapy that is considered experimental, investigational, or unproven is not a benefit of Texas Medicaid.
Single dose vials (procedure code 95144) are not a benefit of Texas Medicaid.

Texas Medicaid & Healthcare Partnership
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