CG-MED-52 Allergy Immunotherapy (Subcutaneous)

This policy addresses subcutaneous allergy immunotherapy (SCIT), including clinician supervision and the preparation/provision of allergen/antigen extract doses. Coverage is medically necessary for up to 150 preparations per 12 months during the first year (including the build-up phase) and up to 120 preparations per 12 months thereafter as maintenance; quantities above these limits (more than 150 in year 1 or more than 120 in subsequent years) are not medically necessary.

"Supervision (including preparation) and provision of 150 allergen/antigen preparations or less per 12 months of subcutaneous allergy immunotherapy is consideredmedically necessaryfor the first year..."

Sign up to see full coverage criteria, indications, and limitations.