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Anthem Blue Cross ConnecticutCommercial Clinical Policy

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


Subcutaneous Allergy Immunotherapy (First Year)

Notes: Coverage is for the first year, including the build-up phase.

Indications

(517952) Is the supervision and provision for 150 or fewer allergen/antigen preparations per 12 months of subcutaneous allergy immunotherapy? 

Contraindications

(517953) Is the supervision and provision for more than 150 allergen/antigen preparations per 12 months of subcutaneous allergy immunotherapy? 

Subcutaneous Allergy Immunotherapy (After First Year)

Notes: Coverage is after the first year as maintenance therapy.

Indications

(517954) Is the supervision and provision for 120 or fewer allergen/antigen preparations per 12 months of subcutaneous allergy immunotherapy? 

Contraindications

(517955) Is the supervision and provision for more than 120 allergen/antigen preparations per 12 months of subcutaneous allergy immunotherapy? 
Effective Date

04/12/2023

Last Reviewed

02/16/2023

Original Document

  Reference



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.