MSSNY Advocacy Helps Secure Medicare Reimbursement for Allergen Extract Dilutions
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Successful collaboration ensures better patient access and fair physician reimbursement
The American College of Allergy, Asthma, and Immunology (ACAAI) has announced a significant reimbursement victory for allergists and healthcare professionals. Below is their official press release detailing the successful advocacy efforts that led to Medicare reimbursement for allergen extract dilutions.
The American College of Allergy Asthma and Immunology Council (ACAAI) is thrilled to announce that, as a result of our successful meetings with the Medicare Administrative Contractor (MAC) for the Northeast Region – National Government Services – it has agreed to reimburse allergists and other health care professionals for allergen extract dilutions. This service area includes New York, and several other states (Connecticut, Illinois, Maine, Massachusetts, Minnesota, New Hampshire, Rhode Island, Vermont, and Wisconsin).
National Government Services made the following statement: “NGS will cover CPT code 95165, when medically reasonable and necessary for preparation and provision of maintenance and build up doses of antigens for allergen immunotherapy.”
The College wishes to express our sincere gratitude to the Medical Society of the State of New York (MSSNY) for its partnership in this effort. MSSNY staff streamlined the process and allowed us to contact the correct people at NGS quickly, allowing the patients and doctors of New York easier access to this disease-altering therapy. “We could have wasted countless hours pursuing this effort without the assistance of MSSNY; partnerships like this one are the foundation of effective advocacy,” according to J. Allen Meadows, M.D., Executive Director of Advocacy and Government Affairs of the ACAAI. Particular thanks go to MSSNY members Purvi S. Parikh, M.D. and Audrey Weissman, M.D. for supporting this effort.
This policy only applies to practices in states for which National Government Services is the MAC. Additionally, as previously announced, the Palmetto (Southeast) Region and Noridian (West) Region have adopted similar policies, bringing dilution coverage to 30 states!
However, it is important to note that Medicare has assigned medically unlikely edits (MUEs) of 30 units per day for CPT code 95165. The MUEs are the maximum unit(s) of service that can be reported for a single beneficiary on the same date of service. Claims in excess of the MUE number of units are considered “medically unlikely.” Also, Medicare continues to define a dose as 1ml, unlike the CPT definition.
We must also acknowledge the important work done in this effort in partnership with the Advocacy Council by Ned DeLozier of The Allergy, Asthma and Sinus Center and PME Communications, as well as John Herzog of Kimbell & Associates. We also thank Senator Marsha Blackburn (R-TN) and Senator Bill Cassidy, MD (R-LA), for their assistance with CMS in this effort.
IMPORTANT: The information contained herein is provided for educational purposes only and should not be construed or relied upon as legal advice. If legal advice is required, you should seek the advice of your legal counsel.
