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Preauthorization requirements for CPT code 95165

Moda Health has been monitoring our claims experience and noted that CPT code 95165 has been submitted with a high number of units more often than expected. CPT code 95165 is defined as: "Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses)."

In response, Moda Health is making the following change in our preauthorization requirements and claims processing:

Pre-authorization will be required for more than 56 units of 95165. (56 units = two treatment sets at 28 units/doses per treatment set)

Documentation of medical necessity should include the following information:

If no preauthorization is on file, claims will be pended for review of medical necessity. As a result, your reimbursement will be delayed and the patient will become responsible for any units determined to not be medically necessary.

Links to reference documents:

For Preauthorization, complete the 95165 Preauthorization Request Form, and fax to 503-243-5105, or call 503-243-4496 or toll-free 800-258-2037.

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