Wiki CPT 95165 Allergy Mixing and units

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amwittler

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We got a denial from UnitedHealthcare stating the number of units billed is not supported. Of note, a unit dose for reporting purposes is defined as 1 ml or 1 cc from a single multidose vial with maximum of 10 doses per vial allowed. Is this a payer specific guideline? The provider documentation states that the total volume was 5.0 ml and 10 doses were prepared. We billed out 10 units (95165X10).
 
This issue with UHC is systemic! I am from CT and we are having a major issue. UHC's policy is not transparent, the UHC Rep indicated they were following now CMS Allergy Immunization Therapy Guidelines but no other policy or statement was published. CMS policy indicates each multi-dose vial is limited to 10 billable 1 cc aliquots with an MUE of 30 units per day. With the practice I am dealing with they billed 22 units on the 1st day and then 22 units per 2nd, 3rd & 4th day. The 1st 22 units were paid, the other 3 days were denied for either exceeds maximum allowed or service lacks information, etc. This all started in 2024, where claims were being paid and within a month total payments were retracted; 2025 is when UHC started paying the 1st claim for 22 units but are now denying the next 3 days of claims.

We are fighting with UHC's rep to get us their documented policy and when it started so we know how to proceed. Of note, I reached out to another coder who happens to be in Montana and her response was: No solution other than UHC follows MCR rules so we can only bill out 5 units for 1 vial and 10 units for 2 vials instead of the 10 units or 20 units other insurances allow. So again we get shorted as providers.

Anyone out there that can provide any additional advise or insight, please respond.

Thank you!
Jennifer - CPC/CRC/CPMA
CT
 
amwittler said:
We got a denial from UnitedHealthcare stating the number of units billed is not supported. Of note, a unit dose for reporting purposes is defined as 1 ml or 1 cc from a single multidose vial with maximum of 10 doses per vial allowed. Is this a payer specific guideline? The provider documentation states that the total volume was 5.0 ml and 10 doses were prepared. We billed out 10 units (95165X10).
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This isn't my area of expertise but does this help?
When a multidose vial contains less than 10cc, physicians should bill Medicare for the number of 1 cc aliquots that may be removed from the vial. That is, a physician may bill Medicare up to a maximum of 10 doses per multidose vial, but should bill Medicare for fewer than 10 doses per vial when there is less than 10cc in the vial.
If it is medically necessary, physicians may bill Medicare for preparation of more than one multidose vial.
EXAMPLES:
(1) If a 10cc multidose vial is filled to 6cc with antigen, the physician may bill Medicare for 6 doses since six 1cc aliquots may be removed from the vial.
(2) If a 5cc multidose vial is filled completely, the physician may bill Medicare for 5 doses for this vial.
(3) If a physician removes ½ cc aliquots from a 10cc multidose vial for a total of 20 doses from one vial, he/she may only bill Medicare for 10 doses. Billing for more than 10 doses would mean that Medicare is overpaying for the practice expense of making the vial.
(4) If a physician prepares two 10cc multidose vials, he/she may bill Medicare for 20 doses. However, he/she may remove aliquots of any amount from those vials. For example, the physician may remove ½ aliquots from one vial, and 1cc aliquots from the other vial, but may bill no more than a total of 20 doses.
(5) If a physician prepares a 20cc multidose vial, he/she may bill Medicare for 20 doses, since the practice expense is calculated based on the physician’s removing 1cc aliquots from a vial. If a physician removes 2cc aliquots from this vial, thus getting only 10 doses, he/she may nonetheless bill Medicare for 20 doses because the PE for 20 doses reflects the actual practice expense of preparing the vial.
(6) If a physician prepares a 5cc multidose vial, he may bill Medicare for 5 doses, based on the way that the practice expense component is calculated.

You can find the full Medicare policy in Section 200 of Chapter 12 of the Medicare Claims Processing Manual at https://www.cms.gov/regulations-and...ls/internet-only-manuals-ioms-items/cms018912.
 
Thank you Cynthia, you are 100% correct, unfortunately UHC is not playing fair and is inconsistent with the denials and claim processing. Just looking for anyone out there that has had success in billing UHC without a problem.

Jennifer
 
Having the same issue here. My real question is, is a actual coder at UHC reviewing these records and denying or is this just being held up in an AI generated billing system that automatically denies no matter what? Because if an actual person is reviewing these records and is denying, there should be something in writing to back up what they are doing.
 
UHC follows Medicare rules, If the total volume is 5.0 ml, and 10 doses were prepared, this implies each dose was 0.5 ml, which does not meet the 1 ml per unit standard for a dose. Therefore, billing 10 units of 95165 may be denied by UHC because they expect 1 unit = 1 ml, and only 5 ml was prepared. Therefore only 5 doses should have been billed if this was Medicare or if this was UHC. UHC is not doing anything wrong by imposing this there are two different definitions of a dose, and they are aligning with Medicare.
 
Has anyone had any luck with UHC and billing the serums under 95165. We make the maintenance vial 1st, so from what I understand, is that we can only bill 20units for 2 10ml vials, eventhough our plan of treatment is 300 units, they are only going to pay for those first 2 vials of antigens?
 
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