Allergen Immunotherapy

Allergen immunotherapy (subcutaneous) is covered when the patient has documented, clinically relevant specific IgE-mediated sensitization that correlates with exposure and symptoms, and when avoidance measures have failed or exposure is unavoidable. Covered conditions include allergic rhinitis, conjunctivitis, allergic asthma, dust-mite atopic dermatitis, and stinging insect hypersensitivity (specified insects); multiple routes, certain formulations, food allergy immunotherapy, and routine home administration are excluded. Therapy requires documentation of testing and failed avoidance, appropriate provider qualifications, in-office administration with at least 30-minute observation, individualized dosing schedules (build-up 8–28 weeks, maintenance 2–8 week intervals), and treatment duration individualized with typical courses of 3–5 years and presumption of failure after 12–24 months if no benefit.

"Allergen immunotherapy is medically reasonable and necessary when there is demonstrable evidence of specific IgE antibodies to clinically relevant allergens that correlate with the patient’s exposu..."