Sublingual immunotherapy using Oralair, Grastek, or Ragwitek may be considered medically necessary, when used according to U.S. Food and Drug Administration (FDA) labeling, for the treatment of pollen-induced allergic rhinitis or rhinoconjunctivitis when the following conditions are met:
Patient has a history of rhinitis or rhinoconjunctivitis symptoms related to grass or short ragweed pollen exposure.
Patient has a documented positive pollen-specific skin test or pollen-specific immunoglobulin E test (see Policy Guidelines section).
Patient’s symptoms are not adequately controlled by appropriate pharmacotherapy (see Policy Guidelines section).
Sublingual immunotherapy using Odactra may be considered medically necessary, when used according to FDA labeling, for the treatment of house dust mite-induced allergic rhinitis or rhinoconjunctivitis when the following conditions are met:
Patient has a history of rhinitis or rhinoconjunctivitis symptoms related to dust mite exposure.
Patient has a documented positive house dust mite-specific skin test or house dust mite-specific immunoglobulin E test (see Policy Guidelines section).
Patient’s symptoms are not adequately controlled by appropriate pharmacotherapy (see Policy Guidelines section).
Sublingual immunotherapy as a technique of allergy immunotherapy is considered investigational for all other uses.
