Guidance for the evaluation by payors of claims submitted using Current Procedural Terminology codes 95165, 95115, and 95117

This Guidance was jointly developed equally by the American Academy of Allergy Asthma and Immunology (AAAAI), the American Academy of Otolaryngic Allergy (AAOA), and the American College of Allergy, Asthma and Immunology (ACAAI) to advise insurance companies and other payors of the documentation that they should, and should not, require in their review of claims for payment for services covered by Current Procedural Terminology (CPT) codes 95165, 95115, and 95117. The goal of the Guidance is to assist payors to develop a process for reviewing claims submitted under these 3 codes in a manner that is efficient, fair, and not unduly burdensome. This document supersedes any document or manual published previously by the above organizations.

The Guidance is divided into 2 parts. The first part explains each of the 3 codes, the services that are covered by these codes, and the medical necessity of those services. The second part describes what the 3 organizations believe are reasonable requests for documentation and what we submit are unreasonable requests. It first addresses code 95165 and then codes 95115 and 95117.

The AAAAI, AAOA, and ACAAI recognize that it is reasonable for insurance companies and other payors to request documentation to show that a claim submitted under CPT code 95165, 95115, or 95117 is for a medically necessary service that has been performed and has been properly coded. Accordingly, in this Guidance, we have presented the documentation that in our judgment is reasonable for payors to request. This documentation is itself quite substantial.

At the same time, we respectfully submit that demands for several kinds of additional documentation that have been made by some insurers are unnecessary. These demands serve only to make the claims process less efficient and to impose an undue burden on the entity submitting the claim—at least when the payor has no sound reason to believe that a particular claimant has acted improperly. Whenever we have characterized a particular category of requested documentation as excessive, we have sought to explain the reasons for our position.

All 3 organizations would be pleased to meet with any payor that would like to discuss this Guidance. As noted at the outset, our goal is to work with payors to assist them in developing a process for review of claims under codes 95165, 95115, and 95117 that is efficient, fair, and not unduly burdensome.

The authors declare no conflicts of interest.

The authors have no funding sources to report.