HumanaCommercial Clinical Policy

Humana Allergy Treatments Form


Notes: Coverage is limited to up to 3 visits per week for allergen immunotherapy. Rapid desensitization treatments must be administered in a medical facility. Allergens should be separately prepared for the individual and the allergen content should be based on appropriate skin testing or in vitro testing.

Indications

(841799) Has the patient shown hypersensitivity to allergens that cannot be managed by medications or avoidance? 
(841800) Does the patient have IgE-mediated allergic asthma not sufficiently controlled by optimal allergen avoidance and medications? 
(841801) Does the patient have IgE-mediated anaphylactic reactions to hymenoptera insects? 
(841802) Does the patient have severe, seasonal or perennial IgE-dependent allergic rhinoconjunctivitis where allergen avoidance and medications have not been sufficiently effective? 

Contraindications

(841803) Is the patient seeking allergy treatment for conditions not listed as covered indications, such as acupuncture, angioedema, atopic dermatitis, chronic urticaria, low-dose immunotherapy, or others mentioned in the document? 
YesNoN/A
YesNoN/A
YesNoN/A

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Effective Date

12/14/2023

Last Reviewed

NA

Original Document

  Reference



Description

Immunotherapy is an allergy treatment with the intended goal of decreasing an individual’s sensitivities to allergens, which can be identified through allergy testing. Immunotherapy involves repeated administration, by a series of injections of increasing amounts, of the allergen that caused the abnormal allergic reaction. Immunotherapy is only recommended for the treatment of allergic asthma, allergic rhinitis, conjunctivitis and stinging insect allergies. It is not intended for the treatment of food allergies. The recommended treatment of food allergies is avoidance.

Epicutaneous immunotherapy (EPIT)

EPIT is an allergy treatment that consists of a patch, which contains antigens in a dry form. The patch is secured to the skin by an adhesive overlay, which purportedly creates an occlusive chamber. The patch is designed to gradually expose the individual to an allergen where it is concentrated in the superficial layers of the skin reportedly activating the immune system. An example of this type of immunotherapy is the Viaskin EPIT, which is proprietary for use for the treatment of peanut allergy and has not yet received US Food & Drug Administration (FDA) approval.23 (Refer to Coverage Limitations section)

Sublingual immunotherapy

Sublingual immunotherapy is an alternative way to treat allergies without injections. Small doses of an allergen are placed under the tongue to supposedly boost tolerance and reduce allergy symptoms. (Refer to Coverage Limitations section)

For covered indications and additional information regarding sublingual immunotherapy, please refer to Sublingual Allergen Extract Pharmacy Coverage Policy.

Inhaled allergen particle barriers

(also known as inhaled allergy blockers) are designed to treat inhaled allergies without injections. The products (eg, Alzair, Nasaleze) come in powder form in specially designed dispensers. The powder is inhaled and reportedly forms a mucous-like gel barrier that coats the nasal membrane, which supposedly blocks inhaled allergens. Inhalation filters and gels/creams have also reportedly been utilized to block inhaled allergies.24 (Refer to Coverage Limitations section)

Intranasal immunotherapy

may also be known as local nasal immunotherapy (LNIT) involves the administration of allergen immunotherapy into the nasal cavity. It is reportedly being studied as an alternative to injections for the treatment of allergic rhinitis. (Refer to Coverage Limitations section)

Oral immunotherapy

refers to feeding an allergic individual an increasing amount of an allergen with the goal of increasing the individual’s threshold that triggers a reaction. (Refer to Coverage Limitations section)

For covered indications and additional information regarding oral immunotherapy, please refer to Palforzia (peanut allergen powder) Pharmacy Coverage Policy.

For information regarding allergy testing, please refer to Allergy Testing Medical Coverage Policy.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Coverage Determination

Please refer to the member’s applicable pharmacy benefit to determine benefit availability and the terms and conditions of coverage for medication for the treatment of allergies.

Humana members may be eligible under the Plan for allergy treatments (eg, immunotherapy) for the following indications (limited up to 3 visits per week for allergen immunotherapy)2:

  • Hypersensitivity to allergens that cannot be managed by medications (eg, intranasal, oral) or avoidance; OR
  • IgE-mediated allergic asthma in which optimal allergen avoidance and medications (eg, intranasal, oral) have not been sufficiently effective in controlling symptoms; OR
  • IgE-mediated anaphylactic reactions to hymenoptera insects (bees, fire ants, hornets, wasps); OR
  • Severe, seasonal or perennial IgE-dependent allergic rhinoconjunctivitis where allergen avoidance and medications (eg, intranasal, oral) have not been sufficiently effective in controlling symptoms

Humana members may be eligible under the Plan for rapid desensitization (eg, rush or cluster immunotherapy) when administered in a medical facility, for the following indications:

  • Hymenoptera insects (bees, fire ants, hornets, wasps) hypersensitivity; OR
  • IgE antibodies to a medically necessary drug that cannot be treated with alternative medications

Note: Allergens should be separately prepared for the individual and the allergen content should be based on appropriate skin testing or appropriate in vitro testing.

Allergy Treatments Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0347-022
Page: 4 of 13

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Coverage Limitations

Humana members may NOT be eligible under the Plan for allergy treatments for any indications other than those listed above including, but may not be limited to, the following.

  • Acupuncture; OR
  • Angioedema; OR
  • Atopic dermatitis; OR
  • Chronic urticaria; OR
  • Enzyme-potentiated immunotherapy (low-dose immunotherapy); OR
  • Epicutaneous immunotherapy; OR
  • Immunotherapy based on provocation-neutralization testing; OR
  • Immunotherapy for poison ivy/poison oak; OR
  • Immunotherapy given outside of a medical facility2; OR
  • Inhaled allergen particle barriers (eg, Alzair, Nasaleze); OR
  • Intranasal immunotherapy (local nasal immunotherapy [LNIT]); OR
  • Migraine headaches; OR
  • Oral immunotherapy for food allergies other than what is listed as covered on any applicable Pharmacy coverage policy including, but may not be limited to, Palforzia (peanut allergen powder (generally treated by avoidance and therefore not appropriate for immunotherapy); OR
  • Rhinophototherapy; OR
  • Sublingual immunotherapy other than what is listed as covered on any applicable Pharmacy coverage policy including Sublingual Allergen Extract

Allergy Treatments Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0347-022
Page: 5 of 13

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

For Humana plans that exclude coverage of allergy treatments not approved by the American Academy of Allergy Asthma & Immunology (AAAAI), these technologies would be excluded by certificate.

In the absence of a certificate exclusion, these are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Note: The criteria for provocation-neutralization immunotherapy are consistent with the Medicare National Coverage Policy and therefore apply to Medicare members.

Note: The criteria for sublingual immunotherapy are not consistent with the Medicare National Coverage Policy and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information

Background

Additional information about allergies may be found from the following websites:

  • American Academy of Allergy, Asthma and Immunology
  • National Library of Medicine

Medical Alternatives

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.

Provider Claims Codes

CPT® Code(s)

Description

Description Comments

Allergy Treatments Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0347-022
Page: 6 of 13

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Provider Claims Codes

CPT® Code(s)

  • 95115 Professional services for allergen immunotherapy in the office or institution of the prescribing physician or other qualified health care professional, including provision of allergenic extract; single injection
  • 95117 Professional services for allergen immunotherapy in the office or institution of the prescribing physician or other qualified health care professional, including provision of allergenic extract; 2 or more injections
  • 95120 Professional services for allergen immunotherapy in the office or institution of the prescribing physician or other qualified health care professional, including provision of allergenic extract; single injection
  • 95125 Professional services for allergen immunotherapy in the office or institution of the prescribing physician or other qualified health care professional, including provision of allergenic extract; 2 or more injections
  • 95130 Professional services for allergen immunotherapy in the office or institution of the prescribing physician or other qualified health care professional, including provision of allergenic extract; single stinging insect venom
  • 95131 Professional services for allergen immunotherapy in the office or institution of the prescribing physician or other qualified health care professional, including provision of allergenic extract; 2 stinging insect venoms
  • 95132 Professional services for allergen immunotherapy in the office or institution of the prescribing physician or other qualified health care professional, including provision of allergenic extract; 3 stinging insect venoms
  • 95133 Professional services for allergen immunotherapy in the office or institution of the prescribing physician or other qualified health care professional, including provision of allergenic extract; 4 stinging insect venoms
  • 95134 Professional services for allergen immunotherapy in the office or institution of the prescribing physician or other qualified health care professional, including provision of allergenic extract; 5 stinging insect venoms
  • 95144 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy, single dose vial(s) (specify number of vials)

Allergy Treatments Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0347-022
Page: 7 of 13

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

CPT® Category III Code(s)

No code(s) identified

HCPCS Code(s)

Description

Comments

Allergy Treatments Effective Date: 12/14/2023

Revision Date: 12/14/2023

Review Date: 12/14/2023

Policy Number: HUM-0347-022

Page: 8 of 13

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

References
  • American Academy of Allergy, Asthma and Immunology (AAAAI). Algorithm for the diagnosis and management of asthma: a practice parameter update. https://www.aaaai.org. Published November 1998. Accessed December 1, 2023.
  • American Academy of Allergy, Asthma and Immunology (AAAAI). Allergen immunotherapy: a practice parameter third update. https://www.aaaai.org. Published January 2011. Accessed December 1, 2023.
  • American Academy of Allergy, Asthma and Immunology (AAAAI). Anaphylaxis: a 2020 practice parameter update, systematic review and grading of recommendations, assessment, development and evaluation (GRADE) analysis. https://www.aaaai.org. Published April 2020. Accessed December 1, 2023.
  • American Academy of Allergy, Asthma and Immunology (AAAAI). Atopic dermatitis: a practice parameter update 2012. https://www.aaaai.org. Published February 2013. Accessed December 1, 2023.
  • American Academy of Allergy, Asthma and Immunology (AAAAI). Environmental assessment and exposure control: a practice parameter – furry animals. https://www.aaaai.org. Published 2012. Accessed December 1, 2023.
  • American Academy of Allergy, Asthma and Immunology (AAAAI). Environmental assessment and exposure control of dust mites: a practice parameter. https://www.aaaai.org. Published 2013. Accessed December 1, 2023.
  • American Academy of Allergy, Asthma and Immunology (AAAAI). Environmental assessment and exposure reduction of cockroaches: a practice parameter. https://www.aaaai.org. Published 2013. Accessed December 1, 2023.
  • American Academy of Allergy, Asthma and Immunology (AAAAI). Environmental assessment and exposure reduction of rodents: a practice parameter. https://www.aaaai.org. Published 2012. Accessed December 1, 2023.
  • American Academy of Allergy, Asthma and Immunology (AAAAI). Food allergy: a practice parameter update - 2014. https://www.aaaai.org. Published November 2014. Accessed December 1, 2023.
  • American Academy of Allergy, Asthma and Immunology (AAAAI). Practice Guideline. Treatment of seasonal allergic rhinitis. https://www.aaaai.org. Published 2017. Accessed December 1, 2023.
  • American Academy of Allergy, Asthma and Immunology (AAAAI). Practice Parameter. The diagnosis and management of acute and chronic urticaria: 2014 update. https://www.aaaai.org. Published May 2014. Accessed December 1, 2023.
  • American Academy of Allergy, Asthma and Immunology (AAAAI). Rhinitis 2020: a practice parameter update. https://www.aaaai.org. Published October 2020. Accessed December 1, 2023.
  • American Academy of Allergy, Asthma and Immunology (AAAAI). Stinging insect hypersensitivity: a practice parameter update 2016. https://www.aaaai.org. Published 2017. Accessed December 1, 2023.
  • American Academy of Allergy, Asthma and Immunology (AAAAI). The diagnosis and management of rhinitis: an updated practice parameter. https://www.aaaai.org. Published August 2008. Accessed December 1, 2023.
  • American Academy of Allergy, Asthma and Immunology (AAAAI). The diagnosis and management of sinusitis: a practice parameter update.https://www.aaaai.org. Published December 2005. Accessed December 1, 2023.
  • American Academy of Dermatology (AAD). Guidelines of care for the management of atopic dermatitis. https://www.aad.org. Published July 2014. Accessed December 1, 2023.
  • American Academy of Otolaryngic Allergy (AAOA). Clinical Care Statement. Duration of immunotherapy. https://www.aaoallergy.org. Published January 2018. Accessed December 1, 2023.
  • American Academy of Otolaryngic Allergy (AAOA). Clinical Care Statement. Home subcutaneous immunotherapy. https://www.aaoallergy.org. Published January 2018. Updated February 14, 2020. Accessed December 1, 2023.
  • American Academy of Pediatrics (AAP). Consensus communications on early peanut introduction and the prevention of peanut allergy in high-risk infants. https://www.aap.org. Published September 2015. Accessed December 1, 2023.
  • American Gastroenterological Association (AGA). AGA Institute and Joint Task Force on Allergy-Immunology practice parameters clinical guidelines for the management of eosinophilic esophagitis. https://www.gastro.org. Published May 2020. Accessed December 1, 2023.
  • Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD).

Allergy Treatments Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0347-022
Page: 9 of 13

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Antigens prepared for sublingual administration (110.9). https://www.cms.gov. Published November 17, 1996. Accessed December 9, 2023.
  • Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Food allergy testing and treatment (110.11). https://www.cms.gov. Published October 31, 1988. Accessed December 9, 2023.

Allergy Treatments Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0347-022
Page: 11 of 13

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Hayes, Inc. Emerging Technology Report. Viaskin epicutaneous immunotherapy (EPIT) for peanut allergy. https://evidence.hayesinc.com. Published May 30, 2023. Accessed December 9, 2023.
  • Hayes, Inc. Evidence Analysis Research Brief. Alzair allergy blocker (Nasaleze International) for treatment of allergic rhinitis in adults. https://evidence.hayesinc.com. Published March 17, 2023. Accessed September 12, 2023.
  • Hayes, Inc. Health Technology Assessment. Acupuncture for the treatment of allergic rhinitis. https://evidence.hayesinc.com. Published May 18, 2021. Updated May 25, 2023. Accessed November 29, 2023.
  • MCG Health. Immunotherapy, oral. 27th edition. https://www.mcg.com. Accessed July 27, 2023.
  • MCG Health. Immunotherapy, subcutaneous. 27th edition. https://www.mcg.com. Accessed July 27, 2023.
  • MCG Health. Immunotherapy, sublingual. 27th edition. https://www.mcg.com. Accessed July 27, 2023.
  • National Heart, Lung and Blood Institute (NHLBI). 2020 focused update to the asthma management guidelines. https://www.nhlbi.nih.gov. Published December 2020. Accessed December 1, 2023.
  • National Heart, Lung and Blood Institute (NHLBI). Expert panel report 3: guidelines for the diagnosis and management of asthma. https://www.nhlbi.nih.gov. Published August 28, 2007. Accessed December 1, 2023.
  • National Institute of Allergy and Infectious Diseases (NIAID). Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel. https://www.niaid.nih.gov. Published December 2010. Accessed December 1, 2023.

Allergy Treatments Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0347-022
Page: 12 of 13

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • UpToDate, Inc. Experimental therapies for food allergy: immunotherapy and nonspecific therapies. https://www.uptodate.com. Updated October 2023. Accessed November 29, 2023.
  • UpToDate, Inc. Allergen immunotherapy for allergic disease: therapeutic mechanisms. https://www.uptodate.com. Updated October 2023. Accessed November 29, 2023.
  • UpToDate, Inc. Allergic conjunctivitis: management.https://www.uptodate.com. Updated October 2023. Accessed November 29, 2023.
  • UpToDate, Inc. Anti-IgE therapy. https://www.uptodate.com. Updated October 2023. Accessed November 29, 2023.
  • UpToDate, Inc. Grain allergy: clinical features, diagnosis and management. https://www.uptodate.com. Updated October 2023. Accessed November 29, 2023.
  • UpToDate, Inc. Latex allergy: management. https://www.uptodate.com. Updated October 2023. Accessed November 29, 2023.
  • UpToDate, Inc. Rush and ultra-rush venom immunotherapy for hymenoptera allergy. https://www.uptodate.com. Updated October 2023. Accessed November 29, 2023.
  • UpToDate, Inc. SCIT: preparation of allergen extracts for therapeutic use. https://www.uptodate.com. Updated October 2023. Accessed November 29, 2023.

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  • UpToDate, Inc. SCIT: standard schedules, administration techniques, adverse reactions and monitoring. https://www.uptodate.com. Updated October 2023. Accessed December 8, 2023.
  • UpToDate, Inc. Stings of imported fire ants: clinical manifestations, diagnosis and treatment. https://www.uptodate.com. Updated October 2023. Accessed November 29, 2023.

Allergy Treatments Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0347-022
Page: 13 of 13

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • UpToDate, Inc. Subcutaneous aeroallergen immunotherapy: accelerated schedules (cluster and rush). https://www.uptodate.com. Updated October 2023. Accessed November 29, 2023.
  • UpToDate, Inc. Subcutaneous immunotherapy (SCIT) for allergic rhinoconjunctivitis and asthma: indications and efficacy. https://www.uptodate.com. Updated October 2023. Accessed November 29, 2023.
  • UpToDate, Inc. Sublingual immunotherapy for allergic rhinitis and conjunctivitis: SLIT-tablets. https://www.uptodate.com. Updated October 2023. Accessed November 29, 2023.