Allergists are seeing a growing number of claim denials for CPT code 95165 – professional services for supervising the preparation and provision of antigens for allergen immunotherapy – when claims are processed through Optum, a subsidiary frequently used by UnitedHealthcare and some other health plans, including some BC/BS plans.
Claims are being denied with remarks indicating that the date of service (DOS) should reflect the date the antigen was dispensed (or provided to the patient), not the date it was mixed/prepared. Documentation must support that the antigen was dispensed rather than merely mixed. The denial language often includes notes such as:
- “The submitted medical records do not support the date of service billed.”
- “The date of service should be the date the antigen was dispensed (not mixed).”
- “The number of units billed as the actual number of doses is not specified.”
This shift appears to require billing 95165 when the prepared extract is administered to the patient, rather than on the preparation/mixing date. This may create practical difficulties for patient-specific treatment sets. Preparing extracts in advance is standard to ensure availability for build-up or maintenance schedules, but if a patient discontinues therapy, pre-prepared antigen may be wasted – yet billing only upon dispensation could limit reimbursement for preparation efforts.
This is not a universal change across all Optum/UHC managed payers. However, some insurers have long required billing only when doses are administered or vials are opened. The current wave of Optum-related denials seems to enforce a stricter interpretation, potentially aligning with policies that tie reimbursement more closely to patient receipt/administration to prevent over-preparation billing.
What this means for practices
These requirements can significantly impact allergy practices that rely on preparing customized, multi-dose vials in advance. Attempting to comply may involve:
- Aligning billing dates with actual dispensation (e.g., when vials are provided to the patient or are first administered)
- Maintaining thorough documentation, including dispensation dates, mixing logs and formulas, lot numbers, expiration dates, and the quantity of doses or units
- Appealing denials with supporting records, such as visit notes, preparation logs, and evidence of medical necessity
Practices should review their individual Optum/UHC contracts and payer policies closely, as rules vary by plan. Contacting the payer for clarification is recommended, though College member experiences suggest responses from Optum/UHC can be limited or delayed.
Advocacy and resources
The College continues to advocate for fair reimbursement and reasonable documentation requirements for 95165, 95115, and 95117. Recent joint guidance addresses burdensome documentation demands by payers, emphasizing that certain requests are unnecessary while supporting efficient, fair claim reviews.
The College continues to monitor this issue. No widespread advance announcement of this specific Optum/BCBS change has been identified, which complicates compliance. UHC and Optum have not responded to attempts by the College to advocate for our members over the last several years.
We encourage members to share experiences with the College and consider appealing denials systematically. If your practice is affected, document everything meticulously and consider consulting your billing specialist or compliance expert for tailored strategies. The College remains committed to supporting allergists in navigating these challenges to ensure continued access to effective immunotherapy for patients.
The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.
