Recent changes associated with the implementation of new Local Coverage Determinations (LCDs) and billing articles for allergen immunotherapy have inadvertently led to systematic denials of claims for venom immunotherapy administration codes CPT 95115 (single injection) and 95117 (multiple injections) when billed alongside venom extract provision codes (95145–95149).
This issue began appearing last fall, affecting multiple Medicare Administrative Contractors (MACs), including Palmetto GBA, Noridian, WPS, and likely others. Denials typically cite reason code CO-50 (non-covered services due to lack of medical necessity).
In a recent College letter to the Palmetto MAC, we highlighted the fact that venom subcutaneous immunotherapy (SCIT) has long been covered under separate national Medicare guidance. The relevant LCD (e.g., L40050) explicitly states that “SCIT with other allergens, such as venoms, is not considered in this LCD,” meaning venom immunotherapy should not be subject to the same diagnostic restrictions as standard aeroallergen therapy.
This appears to be an oversight in system updates rather than an intentional policy change, creating significant access-to-care concerns.
Positive development from Palmetto GBA
In December, Palmetto GBA Medical Affairs confirmed receipt of detailed examples of these denials and a comprehensive list of appropriate venom-related ICD-10 codes submitted by the College. In correspondence, Palmetto representatives indicated they are actively working to correct the issue. While full resolution across all affected MACs may take time, this is an encouraging step forward.
Recommended billing practices in the interim
To minimize further denials and facilitate potential reprocessing:
- Resubmit denied claims in about six weeks. Be sure to use appropriate venom-specific ICD-10 codes. Practices should monitor for updated billing guidance from your MAC.
- Hold submission of new/future claims for venom injection codes (95115/95117) until mid-February or until your MAC publishes confirmation of the correction. This will reduce administrative burden from widespread denials and position claims for cleaner processing once systems are updated.
The Advocacy Council will continue to monitor developments closely and provide updates if new information becomes available from Palmetto GBA or other MACs.
The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.
