New guidance for payers related to unreasonable documentation for immunotherapy

Newly published guidance from the American College of Allergy, Asthma & Immunology (ACAAI), the American Academy of Allergy, Asthma & Immunology (AAAAI) and the American Academy of Otolaryngic Allergy (AAOA) tackles a vital issue facing allergists by providing practical recommendations to insurance companies and other third-party payers regarding appropriate documentation requirements for allergen immunotherapy. “Guidance for the evaluation by payors of claims submitted using Current Procedural Terminology Codes 95165, 95115, and 95117” was developed by a work group initiated by ACAAI that included representatives of all three societies. It is published in the International Forum of Allergy & Rhinology.

“Burdensome and unreasonable requests for documentation regarding these services threaten the ability of allergists/immunologists and otolaryngologists to administer this type of therapy,” says allergist J. Allen Meadows, MD, FACAAI, Executive Director of Advocacy and Government Affairs for ACAAI, and lead author of the paper. “It also hinders the ability of patients with allergic conditions to obtain relief.”

“It is important that we work together to protect patient access to allergen immunotherapy, which we know helps keep students in school and adults at work, and can save lives,” added AAAAI President Paul Williams, MD, FAAAAI, and a co-author of the paper. “Unreasonable requirements for documentation resulting in reduced access to this therapy undermine our ability to provide excellent patient care.”

AAOA President Doug Dawson, MD, FAAOA, concurs. “Educating payers on appropriate reimbursement and documentation is a key step toward patient access.”

The goal of this guidance is to assist payers in developing a process for reviewing claims submitted under CPT Codes 95165, 95115, and 95117 in a way that is “efficient, fair and not unduly burdensome.”

According to the recommendations, all the procedures covered by the three codes are medically necessary for patients suffering from allergic rhinitis, asthma, or atopic dermatitis. Yet, according to the newly published paper, “In recent years, payers have increasingly demanded multiple, detailed documentation that is both highly burdensome to the physician and generally unnecessary.” The demands have resulted in significantly delayed payment – or worse, nonpayment for entirely appropriate procedures. These burdensome requirements threaten the ability of patients to receive necessary allergen immunotherapy treatment.

The guidance lays out what the authors see as reasonable and unreasonable requests for documentation for allergy immunotherapy services.

For example, reasonable documentation includes such items as the identity of the physician and patient; a brief description and date of the treatment plan; dosages and dilutions of injections; etc.

The recommendations state that unreasonable requirements include items such as vial expiration dates; full planned treatment schedules; credentials of the person administering the injection; multiple audit requests and more.

The three organizations recognize that it is reasonable for insurance companies and other payers to request documentation to demonstrate that a claim submitted under CPT Code 95165, 95115, or 95117 is for a medically necessary service that has been performed and has been properly coded. At the same time, the authors stress that demands for several kinds of additional documentation that have been made by some insurers are unnecessary.

ACAAI, AAAAI and AAOA recognize the importance of easing these burdens for the benefit of our members and patients.

We thank the members of the guidelines working group:  

ACAAI:
 J. Allen Meadows, MD
 Gary N. Gross, MD
 J. Wesley Sublett, MD

AAAAI:
Paul Williams, MD
Anita Wasan, MD
Amber Patterson, MD
Anil Nanda, MD

AAOA:
Dole Baker, MD
Robert Puchalski, MD
Jami Lucas

James M. Tracy, DO
President
American College of Allergy, Asthma & Immunology

Paul V. Williams, MD
President
American Academy of Allergy, Asthma & Immunology

Douglas Dawson, MD
President
American Academy of Otolaryngic Allergy