Allergy and Immunology Prior Authorization and Denial Guide
Prior authorization requirements and denial patterns for allergy-immunology, including subcutaneous immunotherapy (SCIT) extract preparation rules, subcutaneous and sublingual immunotherapy billing, dupilumab and monoclonal antibody prior authorization for allergic conditions, and allergy testing unit and frequency caps. Grounded in Aetna Medical Policy for immunotherapy, UHC CDG Allergy, and AAAAI/ACAAI practice parameters.
Allergy immunotherapy: SCIT billing separates the professional service component (CPT 95115, 95117 — injection codes) from the allergen preparation component (CPT 95144–95170 — extract preparation codes). Most commercial payers and Medicare cover both components, but require that the extract preparation codes reflect the actual number of antigens in the set. Allergy testing frequency caps: skin testing panels (CPT 95004, 95024, 95027) are limited to 70 tests per encounter by most payers, with annual limits applying to some plans. Specific IgE testing (RAST/ImmunoCAP, CPT 86003) is limited to a medically appropriate panel — unlimited panels without documented clinical indication are denied.
Dupilumab for allergic indications: dupilumab (Dupixent) is approved for atopic dermatitis, asthma, CRSwNP, eosinophilic esophagitis, and prurigo nodularis. Prior authorization requirements vary by indication — for CRSwNP (CPT J0173), documentation of bilateral nasal polyps confirmed by endoscopy or imaging, prior intranasal corticosteroid use, and for some payers, prior sinus surgery or indication that surgery is contraindicated. For severe asthma, documentation of inadequate control on high-dose ICS/LABA, eosinophil count or FeNO measurement, and prior biologic therapy history where applicable.