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).
CPT 95165 covers physician preparation and provision of non-venom allergen antigen extracts (includes calculations for concentration and volume) but does not include administration of the antigen.
Payment may be made for antigens prepared for a particular patient when the antigens are prepared by a Doctor of Medicine (MD) or Doctor of Osteopathy (DO) who has examined the patient and determined a treatment plan and dosage regimen.
Antigens must be administered in accordance with the physician's plan of treatment and may be given by an MD/DO or a properly instructed person under physician supervision.

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

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

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A60275 — Billing and Coding: Allergen Immunotherapy (AIT) with Subcutaneous Immunotherapy (SCIT)

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A57472 — Billing and Coding: Allergy Immunotherapy

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