MLN Matters Number: SE0812                                               Related Change Request (CR) #: N/A
Related CR Release Date: N/A                                                  Effective Date: N/A
Related CR Transmittal #: N/A                                                 Implementation Date: N/A

Use of Professional Society Practice Parameters in Properly Providing Allergen Immunotherapy to Medicare Beneficiaries

Provider Types Affected
All physicians and providers who submit Medicare claims for providing Allergen Immunotherapy to Medicare beneficiaries

Provider Action Needed
This special edition (SE) article SE0812 is in response to recommendations made by the Department of Health and Human Services (DHHS), Office of Inspector General (OIG) in its 2006 “Allergen Immunotherapy for Medicare Beneficiaries” report. This article provides guidance and resources, developed by professional societies, for Medicare contractors and providers in determining the most appropriate provisions of allergen immunotherapy to Medicare beneficiaries.

Background
The Centers for Medicare & Medicaid Services (CMS) does not have a national coverage determination (NCD) that identifies national coverage criteria for allergen immunotherapy services. Currently coverage of allergen immunotherapy services is at the local Medicare contractor’s discretion. The February 2006 “Allergen Immunotherapy for Medicare Beneficiaries” report released by the DHHS, OIG identified areas of Medicare vulnerability due to insufficient available information regarding coverage, coding, and documentation requirements for physicians who provide allergen immunotherapy to Medicare beneficiaries.

Key Points

• Because allergen immunotherapy may vary significantly based on geographical locations, CMS, with the support of the Joint Council of Allergy, Asthma, and Immunology (JCAAI), decided that an NCD was not the best mechanism for providing coverage to beneficiaries throughout the nation.
• CMS determined that contractor discretion for coverage of allergen immunotherapy is most appropriate.
• Without an NCD, Medicare contractors may develop their own local coverage determinations (LCD).
• While these policies may vary between contractors, CMS strongly encourages physicians who provide allergen immunotherapy to closely follow practice parameters agreed upon and endorsed by the professional societies that represent allergy, asthma, and immunology practitioners (like the Joint Council of Allergy, Asthma, and Immunology (JCAAI)), as long as those parameters fall within the coverage criteria of applicable LCDs.
• Specific practice parameters are provided on the JCAAI Web site at http://www.jcaai.org/ and are important for all practitioners and providers to study and understand.

Additional Information
The CMS Web site provides a searchable database of LCDs, which is available at http://www.cms.hhs.gov/mcd/search.asp on the CMS Web site.

Providers may also wish to review the Medicare NCD Manual, which is available at http://www.cms.hhs.gov/Manuals/IOM/list.asp on the CMS site.

Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.

News Flash -The Centers for Medicare & Medicaid Services (CMS) is pleased to announce that a new educational resource, the 2008 PQRI Fact Sheet, has been posted to the Physician’s Quality Reporting Initiative (PQRI) Web page on the CMS website. This Fact Sheet provides an overview of the 2008 Physician Quality Reporting Initiative. To access this new and all available PQRI educational resources, visit http://www.cms.hhs.gov/PQRI on the CMS Web site and click on the Educational Resources tab. Once on the Educational Resources page, scroll down to the “Downloads” section and click on the “2008 PQRI Fact Sheet” link.

Posted: 04/18/2008