Question UHC max units on 95165

[shollis]

Hi! Trying to get some clarity on UHC's new max # of units per day changing from 75 to 30 on 95165. It was our understanding that the 75 units meant the # of cc's created but now that the max unit is now 30, did that change to # of doses or would we still only consider the cc's mixed?
We've reached out to our provider rep as the policy does not specify, she simply sent back the policy we cited with no explanation; she has yet to respond to our second query. (policy attached) Does anyone have any insight? Is a unit a "dose" or "cc mixed?" Thanks

 

[iowagirl77]

Hi! Trying to get some clarity on UHC's new max # of units per day changing from 75 to 30 on 95165. It was our understanding that the 75 units meant the # of cc's created but now that the max unit is now 30, did that change to # of doses or would we still only consider the cc's mixed?
We've reached out to our provider rep as the policy does not specify, she simply sent back the policy we cited with no explanation; she has yet to respond to our second query. (policy attached) Does anyone have any insight? Is a unit a "dose" or "cc mixed?" Thanks

According to CMS:
CPT procedure code 95165 is used to report multiple dose vials of non-venom antigens. Effective January1, 2001, for CPT code 95165, a dose is now defined as a one- (1) cc aliquot from a single multidose vial. When billing code 95165, providers should report the number of units representing the number of 1 cc doses being prepared. A maximum of 10 doses per vial is allowed for Medicare billing, even if more than ten preparations are obtained from the vial. In cases where a multidose vial is diluted, Medicare should not be billed for diluted preparations in excess of the 10 doses per vial allowed under code 95165. Reference: https://downloads.cms.gov/medicare-coverage-database/lcd_attachments/34597_9/L34597_ALRG001_BCG.pdf

It does look like the MUE is 30, but it has an adjudication indicator of 3, so you should be able to appeal the additional units above 30.