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Contractor Information

Contractor Name: Wisconsin Physicians Service Insurance Corporation - Full list of policies of this Medicare Contractor Contractor Number: 05302 Contractor Type: MAC B

LCD Information

LCD ID Number: L36408 Status: A-Approved LCD Title: Allergen Immunotherapy (AIT) with Subcutaneous Immunotherapy (SCIT) Geographic Jurisdiction: Missouri - Entire State, Missouri - Northwestern Other Jurisdictions Original Determination Effective Date: 03/18/2016 Original Determination Ending Date: Revision Effective Date: 10/26/2025 Revision End Date: CMS National Coverage Policy: Title XVIII of the Social Security Act, §1862 (a)(1)(A) allows coverage and payment for only those items or services that are considered to be medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §50.2 Determining Self-Administration of Drug or Biological and §50.4.4.1 Antigens CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16, §90 Routine Services and Appliances CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2, §110.9 Antigens Prepared for Sublingual Administration and §110.11 Food Allergy Testing and Treatment Sorry, you need to login or register to view additional sections of this Medicare policy. *