Current through Vol. 41, No. 20, July 1, 2024
(a)
Allergy
testing. Allergy testing is the process of identifying allergen(s) that
may cause an allergic or anaphylactic reaction and the degree of the reaction.
By identifying the allergen(s), the member can avoid exposures and the allergic
reaction can be managed appropriately. Treatment options for allergies are
avoidance of the allergen(s), pharmacological therapy, and/or immunotherapy.
Oklahoma Health Care Authority (OHCA) may consider allergy testing medically
necessary when a complete medical, immunological history, and physical
examination is performed and indicates symptoms are suggestive of a chronic
allergy. Allergy testing may also be determined medically necessary if
diagnosis indicates an allergy and simple medical treatment and avoidance of
the allergen(s) were tried and showed inadequate response.
(1)
Coverage. OHCA will provide
reimbursement for allergy testing when the following conditions are met:
(A) Testing is done in a hospital or
providers office under direct supervision of an eligible provider;
(B) The diagnostic testing is based on the
member's immunologic history and physical examination, which document that the
antigen(s) being used for testing have a reasonable probability of exposure in
the members environment;
(C) The
member has significant life-threatening symptomatology or a chronic allergic
state (e.g., asthma) which has not responded to conservative measures;
(D) The member's records document
the need for allergy testing and the justification for the number of tests
performed;
(E) The complete report
of the test results, as well as controls, will be kept as part of the medical
record; and
(F) The member is
observed for a minimum of twenty (20) minutes following allergy testing to
monitor for signs of allergic or anaphylactic reactions.
(2)
Provider requirements. Only
contracted providers (a physician (MD or DO), physician's assistant, or
advanced practice nurse) who are board certified or board eligible in allergy
and immunology or have received training in allergy and immunology in an
accredited academic institution for a minimum of one(1) month clinical rotation
(authenticated by supporting letter from institution or mentor).
(A) Follow-up administration of medically
indicated allergy immunotherapy can be done by a practitioner other than an
allergist.
(B) Allergy testing
and/or immunotherapy for SoonerCare members younger than five(5) years of age
preferably should be performed by an allergy specialist.
(3)
Description of services.
There are a variety of tests to identify the allergen(s) that may be
responsible for the member's allergic response. OHCA covers the following
allergy test(s) for SoonerCare members:
(A)
Direct skin tests:
(i) Percutaneous (i.e.,
scratch, prick, or puncture) tests are performed for inhalant allergies,
suspected food allergies, hymenoptera allergies, or specific drug allergies.
(ii) Intra-cutaneous (i.e.,
intradermal) tests are performed commonly when a significant allergic history
is obtained and results of the percutaneous test are negative or equivocal.
(B) Patch or
application tests;
(C) Photo or
photo patch skin tests;
(D)
Inhalant bronchial challenge testing (not including necessary pulmonary
function tests);
(E) Ingestion
challenge tests (this test is used to confirm an allergy to a food or food
additives); and
(F) Double-blind
food challenge testing.
(G)
Ophthalmic mucous membrane or direct nasal membrane tests, serum allergy tests,
serial dilution endpoint tests, or any unlisted allergy procedure not stated
above will require prior authorization.
(4)
Reimbursement. Reimbursement
for allergy testing is limited to a total of 60 tests every three years. Repeat
allergy testing for the same allergen(s) within three years will require prior
authorization. Any service related to allergy testing beyond predetermined
limits must be submitted with the appropriate documentation to OHCA for prior
authorization consideration.
(5)
Non-covered services. OHCA does not cover allergy testing
determined to be investigational or experimental in nature. For more
information regarding experimental or investigational including clinical
trials, see OAC 317:30-3-57.1.
(b)
Allergy immunotherapy.
Allergy immunotherapy involves administration of allergenic extracts at
periodic intervals, with the goal of reducing symptoms, including titrating to
a dosage that is maintained as maintenance therapy. Allergy immunotherapy is
initiated once the offending allergen(s) has been identified through exposure
and/or allergy testing. The documented allergy should correspond to the
allergen planned for immunotherapy. OHCA may consider allergy immunotherapy
medically necessary for members who have significant life-threatening
symptomology or a chronic allergic state that cannot be managed by medication,
avoidance, or environmental control measures. Before beginning allergy
immunotherapy, consideration must be given to other common medical conditions
that could make allergy immunotherapy more risky.
(1)
Coverage requirements.
Allergy immunotherapy is covered when the following criteria are met and
documented in the medical record:
(A) The
member has allergic asthma, or
(B)
Allergic rhinitis and/or conjunctivitis, or
(C) Life-threatening allergy to hymenoptera
(stinging insect allergy), or
(D)
There is clinical evidence of an inhalant allergen(s) sensitivity; and
(E) Documentation supports that
the member's symptoms are not controlled with medications and avoidance of the
allergen(s) are impractical.
(2)
Provider qualifications. See
OAC 317:30-5-14.1(a)(2) for provider qualifications.
(3)
Administering sites. Allergy
immunotherapy should be administered in a medical facility with trained staff
and proper medical equipment available in the case of significant reaction.
Should home administration be necessary, the following requirements must be
met:
(A) Adequate documentation must be
present in the member's record indicating why home administration is medically
necessary;
(B) Documentation must
indicate the member and/or family member have been properly trained in
recognizing and treating anaphylactic and/or allergic reactions to allergy
immunotherapy administration;
(C)
Epinephrine kits must be available to the member and the family and the member
and/or family have been instructed in its use;
(D) Documentation of member and/or family
member having been properly trained in antigen(s) dosing plan, withdrawing of
correct amount of antigen(s) from the vial and administration of allergy
immunotherapy;
(E) The signed
consent by the member or family member to administer allergy immunotherapy at
home;
(F) The provider initiated
allergy immunotherapy in their office and is planning to continue therapy at
the member's home; and
(G) Signed
acknowledgement by the member or family member of receiving antigen vial(s) as
per treatment protocol.
(4)
Treatment period. A
"treatment period" is generally 90 days, and adequate documentation must be
available for continuation of therapy after each treatment period. The length
of allergy immunotherapy treatment depends on the demonstrated clinical
efficacy of the treatment.
(5)
Reimbursement. Payment is made for the administration of allergy
injections as well as supervision and provision of antigen(s) for adults and
children, with the following considerations:
(A) When a contracted provider actually
administers or supervises administration of the allergy injections, the
administration fee is compensable;
(B) Reimbursement for the administration only
codes is limited to one per member, per day;
(C) No reimbursement is made for
administration of allergy injections when the allergy injection is
self-administered by the member; and
(D) For antigens purchased by the provider
for supervision, preparation and provision for allergy immunotherapy, an
invoice reflecting the purchase should be made available upon request for
post-payment review.
(6)
Limitations. The following limitations and restrictions apply to
immunotherapy:
(A) A presumption of failure
can be assumed if, after twelve (12) months of allergy immunotherapy, the
member does not experience any signs of improvement, and all other reasonable
factors have been ruled out.
(B)
Documented success of allergy immunotherapy treatment is evidenced by:
(i) A noticeable decrease of hypersensitivity
symptoms, or
(ii) An increase in
tolerance to the offending allergen(s), or
(iii) A reduction in medication usage.
(C) Very low dose
immunotherapy or continued submaximal dose has not been shown to be effective
and will be denied as not medically necessary.
(D) Liquid antigen(s) prepared for sublingual
administration are not covered as they have not been proven to be safe and
effective.
(E) Food and Drug
Administration (FDA) approved oral desensitization therapies may be covered as
part of the member's pharmacy benefits and requires prior authorization.
(F) If a provider is preparing
single dose vials of antigens to be administered by a different provider,
member or family member, only thirty (30) units per treatment period of ninety
(90) days with a limit of one hundred and twenty (120) units per year is
allowed. Additional units above the stated limits will require prior
authorization.
(G) If using
multi-dose vials, there is a limitation of 10 units per vial, with a maximum of
twenty (20) units allowed per ninety (90) day treatment period. There is a
limit of 80 units allowed per year. Additional units above the stated limits
will require prior authorization.
(7)
Non-covered services.
Allergy immunotherapy determined by OHCA to be investigational or experimental
will not be covered.For more information regarding experimental or
investigational including clinical trials, see OAC 317:30-3-57.1.