Does 95165 require prior authorization?

No, 95165 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 95165?

Medicare facility rate: $2.67. Non-facility rate: $17.37. Work RVU: 0.06.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

0.06

Facility

$2.67

Non-Facility

$17.37

Maintain all documentation in the patient's medical record and make it available to the contractor upon request.
Every page of the medical record must be legible and include patient identification information (e.g., full name, dates of service).
The medical record must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
The submitted medical record must support the selected ICD-10-CM code(s) used for billing.

Allergen immunotherapy is covered only when it meets the reasonable and necessary requirements specified in Local Coverage Determination (LCD) L36240.
Allergen immunotherapy is covered only when it meets the reasonable and necessary requirements specified in Local Coverage Determination L37800.
Allergen immunotherapy administered in a home setting is allowable if documentation demonstrates that the benefits of home administration outweigh the risks and includes the patient's informed consent and validation of the administrator's training to recognize and manage immunotherapy reactions (including anaphylaxis).
Medicare payment is allowed for preparation/provision of antigens (code 95165) when a physician (MD or DO) prepares the antigen, has examined the patient, and has determined a treatment plan and dosage regimen.
Antigens may be administered by a physician (MD or DO) or by a properly instructed person (including the patient) under the physician's supervision.
Code 95165 covers preparation of vials of non-venom antigens and includes the physician's calculations for concentration and volume based on prior skin test results and patient history.

A60276 — Billing and Coding: Allergen Immunotherapy (AIT) with Subcutaneous Immunotherapy (SCIT)

J05

A57472 — Billing and Coding: Allergy Immunotherapy

J05

L40195 — Allergen Immunotherapy (AIT) with Subcutaneous Immunotherapy (SCIT)

J05

L36408 — Allergen Immunotherapy (AIT) with Subcutaneous Immunotherapy (SCIT)

J05

Ask Verity about documentation requirements, denial risks, or coverage in your state.