317:30-5-14.1. Allergy services
(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.