Anthem Blue Cross Connecticut CG-MED-52 Allergy Immunotherapy (Subcutaneous) Form

This document addresses a quantity of allergy immunotherapy preparations provided in a 12-month time period. Allergy immunotherapy is a form of long-term allergy treatment that decreases sensitivity to allergens and often relieves allergy symptoms. Subcutaneous injections of allergy immunotherapy are a standard clinical approach to decrease allergen sensitivity. Typically, an initial induction or build-up phase progressively increases the allergen dose followed by multiple years of maintenance injections.

Clinical Indications

Medically Necessary:

Supervision (including preparation) and provision of 150 allergen/antigen preparations or less per 12 months of subcutaneous allergy immunotherapy is considered medically necessary for the first year, including the build-up phase.

Supervision (including preparation) and provision of 120 allergen/antigen preparations or less per 12 months of subcutaneous allergy immunotherapy is considered medically necessary after the first year as maintenance therapy.

Not Medically Necessary:

Supervision (including preparation) and provision of greater than 150 allergen/antigen preparations per 12 months of subcutaneous allergy immunotherapy is considered not medically necessary for the first year, including the build-up phase.

Supervision (including preparation) and provision of greater than 120 allergen/antigen preparations per 12 months of subcutaneous allergy immunotherapy is considered not medically necessary after the first year as maintenance therapy.