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MP 2.01.15 Intravenous or Subcutaneous Histamine Therapy

Medical Policy
Section
Medicine
Original Policy Date
3/31/96
Last Review Status/Date
Reviewed with literature search/2:2005
Issue
4:2005
Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


Description

The intravenous or subcutaneous administration of histamine is proposed as a treatment for headaches, particularly cluster headaches, sudden hearing loss, and Ménière’s syndrome.


Policy

Intravenous histamine therapy is considered investigational for all conditions.


Policy Guidelines

No applicable information


Benefit Application

BlueCard/National Account Issues

This policy is applicable for contracts or certificates of coverage that maintain an exclusion for investigational services.


Rationale

Interest in the therapeutic use of histamine was prompted by the 1937 observation that infusions of intravenous histamine provoked the onset of headaches. This led to the use of chronic intravenous or subcutaneous histamine as a type of desensitization therapy. However, no controlled clinical trials have isolated and validated the efficacy of histamine desensitization, and, in general, this therapy has become discredited over time. (1, 2)

No articles describing the clinical effects of histamine therapy in sudden hearing loss or Ménière’s disease were identified.

A literature search of the MEDLINE database performed for the period of 2004 through June 2005 failed to identify any additional published articles. The policy statement is unchanged.

References:

  1. Campbell JK. The current status of histamine desensitization in the treatment of cluster headache. In: Mathew NT (ed). Cluster Headache. Jamaica, NY: Spectrum Publishers, 1984.
  2. Sjaastad O. Cluster Headache Syndrome. Philadelphia, PA: WB Saunders, 1992.

 

Codes

Number

Description

CPT  90774  Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug (new code effective 1/1/06) 
ICD-9 Procedure  99.29  Injection or infusion of other therapeutic or prophylactic substance 
ICD-9 Diagnosis    Investigational for all codes 
HCPCS  No code   
Type of service  Medical 
Place of service  Outpatient
 
Inpatient
 
Home
 


Index

Histamine Therapy, Intravenous
Intravenous Histamine Therapy


Policy History

Date Action Reason
03/31/96 Add to Medicine section New policy
07/10/98 Replace policy Updated policy
07/12/02 Replace policy Policy reviewed without literature review; new review date only
04/29/03 Replace policy Policy reviewed without literature review; new review date only
7/15/04 Replace policy Policy updated with literature review; no additional articles identified; policy unchanged. No further review scheduled
08/17/05 Replace policy Policy updated with literature review; no additional articles identified; policy unchanged. No further review scheduled
12/14/05 Replace policy – coding update only CPT coding updated


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