1 Pharmacy Medical Policy Intravenous Immunoglobulin Table of Contents Policy: Commercial Policy History Endnotes Policy: Medicare Information Pertaining to All Policies Forms Coding Information References Policy Number: 310 BCBSA Reference Number: 8.01.05 Related Policies See medical policy #422, RSV Immunoprophylaxis (RSV-IVIg) Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity Note: All requests for indications listed and not listed on the medical policy guidelines may be submitted to BCBSMA Pharmacy Operations by completing the Prior Authorization Form on the last page of this document. Physicians may also submit requests for exceptions via the web using Express PAth which can be found on the BCBSMA provider portal or directly on the web at https://provider.express-path.com . This medication is not covered by the pharmacy benefit. It is covered by the Medical Benefit or as a Home Infusion Therapy. We cover intravenous immunoglobulin (IVIg) for the following diagnoses only: Blood disorders Bone marrow transplant patients (for prevention of infection or GVH prevention) 12, 14, 32 Multiple myeloma and immunoproliferative neoplasms 8 Immune neutropenia 8 Multiple myeloma without mention of remission 8 Multiple myeloma in remission 8 Plasma cell leukemia without mention of remission 8 Plasma cell leukemia in remission 8 Other immunoproliferative neoplasms without mention of remission 8 Other immunoproliferative neoplasms in remission 8 Agranulocytosis 8 Common variable immunodeficiency, severe combined immunodeficiency, Wiskott-Aldrich syndrome, and X-linked immunodeficiency 14 Prevention of infection in patients with primary defective antibody synthesis 14
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Pharmacy Medical Policy Intravenous Immunoglobulin · 2015. 5. 21. · Systemic Lupus Erythematosis1 Other vasculitides besides Kawasaki disease; including vasculitis associated with
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1
Pharmacy Medical PolicyIntravenous Immunoglobulin
Table of Contents Policy: Commercial Policy History Endnotes
Policy: Medicare Information Pertaining to All Policies Forms
Coding Information References
Policy Number: 310BCBSA Reference Number: 8.01.05
Related Policies See medical policy #422, RSV Immunoprophylaxis (RSV-IVIg)
PolicyCommercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Note: All requests for indications listed and not listed on the medical policy guidelines may be submittedto BCBSMA Pharmacy Operations by completing the Prior Authorization Form on the last page of thisdocument. Physicians may also submit requests for exceptions via the web using Express PAth whichcan be found on the BCBSMA provider portal or directly on the web at https://provider.express-path.com.
This medication is not covered by the pharmacy benefit. It is covered by the Medical Benefit or as aHome Infusion Therapy.
We cover intravenous immunoglobulin (IVIg) for the following diagnoses only:
Blood disorders Bone marrow transplant patients (for prevention of infection or GVH prevention)
12, 14, 32
Multiple myeloma and immunoproliferative neoplasms8
Immune neutropenia8
Multiple myeloma without mention of remission8
Multiple myeloma in remission8
Plasma cell leukemia without mention of remission8
Plasma cell leukemia in remission8
Other immunoproliferative neoplasms without mention of remission8
Other immunoproliferative neoplasms in remission8
Agranulocytosis8
Common variable immunodeficiency, severe combined immunodeficiency, Wiskott-Aldrich syndrome,and X-linked immunodeficiency
14
Prevention of infection in patients with primary defective antibody synthesis14
Chronic lymphocytic leukemia (CLL) with frequent infections12,14
Idiopathic thrombocytopenic purpura (ITP).12,24
Infectious diseases HIV and AIDS
13
Prevention of infection in HIV-infected children12,14
Prior to solid organ transplant, treatment of patients at high risk of antibody-mediated rejection,including highly sensitized patients, and those receiving an ABO incompatible organ
Solid organ transplant recipients at risk for cytomegalovirus infections and pneumonia.7
for severe exacerbations causing disability Myasthenic crisis (i.e., an acute episode of respiratory muscle weakness) in patients with
contraindication to plasma exchange27
Myasthenia gravis in patients with chronic debilitating disease in spite of treatment withcholinesterase inhibitors, or complications from or failure of steroids and/or azathioprine.
Hereditary and idiopathic peripheral neuropathy8, 19
Peroneal muscular atrophy8, 19
Hereditary sensory neuropathy8, 19
Refsum’s disease8
Idiopathic progressive polyneuropathy8
Multiple Sclerosis: for patients with relapsing-remitting disease (not primary or secondary progressiveMS)
Demyelinating polyneuropathy associated with IgM paraproteinemia20
Multifocal motor neuropathy in patients with GM1 antibodies and conduction block15
Stiff-man syndrome35
(Covered for Medicare HMO Blue and Medicare PPO Blue members only,effective 6/07/2010).
Other: Dermatomyositis/polymyositis Refractory dermatomyositis; in combination with other immunosuppressive agents Kawasaki syndrome
12,15
Pemphigus vulgaris (Effective 10/01, coverage is provided as once in a lifetime benefit only, seedosing guideline below)
9
Prior to solid organ transplant; treatment of patients at high risk of antibody-mediated rejection,including highly sensitized patients, and those receiving an ABO incompatible organ
34,Effective
January 2007 Following solid organ transplant; treatment of antibody-mediated rejection
34,Effective January 2007.
We cover intravenous immunoglobulin (IVIg) for treatment of the following biopsy-proven conditions, forour Medicare HMO Blue and Medicare PPO Blue members only, in accordance with CMS guidelines.See endnote 26 for policy guidelines:
26
Pemphigus foliaceus26
Bullous pemphigoid26
Mucous membrane pemphigoid (also known as Cicatrical pemphigoid)26
Epidermolysis bullosa acquisita.26
3
Treatment dosage varies according to indication and preparation used. The following dosage schedulehave been suggested by Medicare:
8
Primary humoral immunodeficiency 100 to 500 mg/kg IV, every monthIdiopathic thrombocytopenic purpura 2 gm/kg for induction and up to 1 gm/kg
subsequently.18
Chronic lymphocytic leukemia 100 to 500 mg/kg IV, every monthBone marrow transplant recipients 100 to 500 mg/kg IV every month. The usual
treatment for CMV prophylaxis in transplant recipientsshould not exceed 90 days.
Kawasaki syndrome 400 mg/kg per day for 5 daysGuillain-Barre syndrome 400 mg/kg per day for 5 daysChronic severe myasthenia gravis 400 mg/kg per day for 5 daysPemphigus vulgaris
182 gm/kg per course of therapy in a month and 3courses of therapy in a 6-month period.
18Coverage is
provided as once in a lifetime benefit only.
We do not cover intravenous immunoglobulin in the following conditions:
Blood disorders Acquired factor VIII inhibitors
16
Acute lymphoblastic leukemia16
Aplastic anemia16
Diamond-Blackfan anemia16
Hemophagocytic syndrome16
Nonimmune thrombocytopenia16
Red cell aplasia16
Thrombotic thrombocytopenic purpura.30
Rheumatologic diseases Behcet’s syndrome
16
Inclusion body myositis2,16
, because it does not work in this disorder Rheumatoid arthritis
4,16and other connective tissue diseases including systemic lupus erythematosus
Scleroderma10
Systemic Lupus Erythematosis1
Other vasculitides besides Kawasaki disease; including vasculitis associated with anti-neutrophilcytoplasmic antibodies (ANCA; e.g., (Wegener’s granulomatosis, polyarteritis nodosa),Goodpasture’s syndrome, and vasculitis associated with other connective tissue diseases.
16, 34
Neurologic conditions Epilepsy
16
Multiple sclerosis: primary progressive or secondary progressive types, because it has not beenshown to offer additional health benefits to patients with these types of MS
3,11,16
Paraneoplastic syndromes including but not limited to Lambert-Eaton syndrome16
Stiff-man syndrome (Non-covered for commercial products only).28
Infectious Chronic sinusitis
16
Recurrent otitis media.16
Other Adrenoleukodystrophy
16
Asthma16
Chronic fatigue syndrome16
4
Cystic fibrosis16
Diabetes mellitus16
Hemolytic uremic syndrome16
Idiopathic lumbosacral flexopathy10
Recurrent fetal loss6,16
Recurrent Spontaneous Abortion33
Bullous pemphigoid21
(except for Medicare HMO Blue and Medicare PPO Blue members above) Pemphigus foliaceus
23(except for Medicare HMO Blue and Medicare PPO Blue members above)
(except for Medicare HMO Blue andMedicare PPO Blue members above)
Epidermolysis bullosa aquisita23
(except for Medicare HMO Blue and Medicare PPO Blue membersabove)
Recurrent spontaneous pregnancy loss25
Idiopathic environmental illness29
Myasthenia gravis in patients responsive to immunosuppressive treatment30
Post-infectious sequelae30
Organ transplant rejection30
Uveitis30
Demyelinating optic neuritis30
Recent-onset dilated cardiomyopathy30
Other disorders not listed above.
CPT Codes / HCPCS Codes / ICD-9 CodesThe following codes are included below for informational purposes. Inclusion or exclusion of a code doesnot constitute or imply member coverage or provider reimbursement. Please refer to the member’scontract benefits in effect at the time of service to determine coverage or non-coverage as it applies to anindividual member. A draft of future ICD-10 Coding related to this document, as it might look today, isincluded below for your reference.
Providers should report all services using the most up-to-date industry-standard procedure, revenue, anddiagnosis codes, including modifiers where applicable.
CPT CodesThere is no specific CPT code for this service.
Diagnosis codingICD-9-CMdiagnosiscodes: Code Description042 Human immunodeficiency virus [HIV] disease078.5 Cytomegaloviral disease136.1 Behcet's syndrome203.00 Multiple myeloma, without mention of having achieved remission203.01 Multiple myeloma, in remission203.02 Multiple myeloma, in relapse203.10 Plasma cell leukemia, without mention of having achieved remission203.11 Plasma cell leukemia, in remission203.12 Plasma cell leukemia, in relapse203.80 Other immunoproliferative neoplasms, without mention of having achieved remission203.81 Other immunoproliferative neoplasms, in remission203.82 Other immunoproliferative neoplasms, in relapse204.00 Acute lymphoid leukemia, without mention of having achieved remission204.01 Acute lymphoid leukemia, in remission204.02 Acute lymphoid leukemia, in relapse204.10 Chronic lymphoid leukemia, without mention of having achieved remission204.11 Chronic lymphoid leukemia, in remission204.12 Chronic lymphoid leukemia, in relapse249.00 Secondary diabetes mellitus without mention of complication, not stated as
uncontrolled, or unspecified249.01 Secondary diabetes mellitus without mention of complication, uncontrolled249.10 Secondary diabetes mellitus with ketoacidosis, not stated as uncontrolled, or
unspecified249.11 Secondary diabetes mellitus with ketoacidosis, uncontrolled249.20 Secondary diabetes mellitus with hyperosmolarity, not stated as uncontrolled, or
unspecified249.21 Secondary diabetes mellitus with hyperosmolarity, uncontrolled249.30 Secondary diabetes mellitus with other coma, not stated as uncontrolled, or unspecified249.31 Secondary diabetes mellitus with other coma, uncontrolled249.40 Secondary diabetes mellitus with renal manifestations, not stated as uncontrolled, or
unspecified249.41 Secondary diabetes mellitus with renal manifestations, uncontrolled249.50 Secondary diabetes mellitus with ophthalmic manifestations, not stated as uncontrolled,
or unspecified249.51 Secondary diabetes mellitus with ophthalmic manifestations, uncontrolled249.60 Secondary diabetes mellitus with neurological manifestations, not stated as
uncontrolled, or unspecified249.61 Secondary diabetes mellitus with neurological manifestations, uncontrolled249.70 Secondary diabetes mellitus with peripheral circulatory disorders, not stated as
uncontrolled, or unspecified249.71 Secondary diabetes mellitus with peripheral circulatory disorders, uncontrolled249.80 Secondary diabetes mellitus with other specified manifestations, not stated as
uncontrolled, or unspecified249.81 Secondary diabetes mellitus with other specified manifestations, uncontrolled249.90 Secondary diabetes mellitus with unspecified complication, not stated as uncontrolled,
or unspecified249.91 Secondary diabetes mellitus with unspecified complication, uncontrolled
6
250.00 Diabetes mellitus without mention of complication, type II or unspecified type, not statedas uncontrolled
250.01 Diabetes mellitus without mention of complication, type I [juvenile type], not stated asuncontrolled
250.02 Diabetes mellitus without mention of complication, type II or unspecified type,uncontrolled
250.03 Diabetes mellitus without mention of complication, type I [juvenile type], uncontrolled250.10 Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled250.11 Diabetes with ketoacidosis, type I [juvenile type], not stated as uncontrolled250.12 Diabetes with ketoacidosis, type II or unspecified type, uncontrolled250.13 Diabetes with ketoacidosis, type I [juvenile type], uncontrolled250.20 Diabetes with hyperosmolarity, type II or unspecified type, not stated as uncontrolled250.21 Diabetes with hyperosmolarity, type I [juvenile type], not stated as uncontrolled250.22 Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled250.23 Diabetes with hyperosmolarity, type I [juvenile type], uncontrolled250.30 Diabetes with other coma, type II or unspecified type, not stated as uncontrolled250.31 Diabetes with other coma, type I [juvenile type], not stated as uncontrolled250.32 Diabetes with other coma, type II or unspecified type, uncontrolled250.33 Diabetes with other coma, type I [juvenile type], uncontrolled250.40 Diabetes with renal manifestations, type II or unspecified type, not stated as
uncontrolled250.41 Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled250.42 Diabetes with renal manifestations, type II or unspecified type, uncontrolled250.43 Diabetes with renal manifestations, type I [juvenile type], uncontrolled250.50 Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as
uncontrolled250.51 Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as
uncontrolled250.52 Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled250.53 Diabetes with ophthalmic manifestations, type I [juvenile type], uncontrolled250.60 Diabetes with neurological manifestations, type II or unspecified type, not stated as
uncontrolled250.61 Diabetes with neurological manifestations, type I [juvenile type], not stated as
uncontrolled250.62 Diabetes with neurological manifestations, type II or unspecified type, uncontrolled250.63 Diabetes with neurological manifestations, type I [juvenile type], uncontrolled250.70 Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as
uncontrolled250.71 Diabetes with peripheral circulatory disorders, type I [juvenile type], not stated as
uncontrolled250.72 Diabetes with peripheral circulatory disorders, type II or unspecified type, uncontrolled250.73 Diabetes with peripheral circulatory disorders, type I [juvenile type], uncontrolled250.80 Diabetes with other specified manifestations, type II or unspecified type, not stated as
uncontrolled250.81 Diabetes with other specified manifestations, type I [juvenile type], not stated as
uncontrolled250.82 Diabetes with other specified manifestations, type II or unspecified type, uncontrolled250.83 Diabetes with other specified manifestations, type I [juvenile type], uncontrolled250.90 Diabetes with unspecified complication, type II or unspecified type, not stated as
uncontrolled250.91 Diabetes with unspecified complication, type I [juvenile type], not stated as uncontrolled250.92 Diabetes with unspecified complication, type II or unspecified type, uncontrolled250.93 Diabetes with unspecified complication, type I [juvenile type], uncontrolled277.00 Cystic fibrosis without mention of meconium ileus
7
277.01 Cystic fibrosis with meconium ileus277.02 Cystic fibrosis with pulmonary manifestations277.03 Cystic fibrosis with gastrointestinal manifestations277.09 Cystic fibrosis with other manifestations277.86 Peroxisomal disorders279.00 Hypogammaglobulinemia, unspecified279.01 Selective IgA immunodeficiency279.02 Selective IgM immunodeficiency279.03 Other selective immunoglobulin deficiencies279.04 Congenital hypogammaglobulinemia279.05 Immunodeficiency with increased IgM279.06 Common variable immunodeficiency279.12 Wiskott-aldrich syndrome279.3 Unspecified immunity deficiency283.0 Autoimmune hemolytic anemias283.11 Hemolytic-uremic syndrome284.01 Constitutional red blood cell aplasia284.81 Red cell aplasia (acquired)(adult)(with thymoma)284.89 Other specified aplastic anemias284.9 Aplastic anemia, unspecified287.31 Immune thrombocytopenic purpura287.32 Evans' syndrome287.49 Other secondary thrombocytopenia287.5 Thrombocytopenia, unspecified288.09 Other neutropenia288.4 Hemophagocytic syndromes333.91 Stiff-man syndrome335.10 Spinal muscular atrophy, unspecified335.11 Kugelberg-Welander disease335.19 Other spinal muscular atrophy335.21 Progressive muscular atrophy337.00 Idiopathic peripheral autonomic neuropathy, unspecified337.01 Carotid sinus syndrome337.09 Other idiopathic peripheral autonomic neuropathy340 Multiple sclerosis345.00 Generalized nonconvulsive epilepsy, without mention of intractable epilepsy345.01 Generalized nonconvulsive epilepsy, with intractable epilepsy345.10 Generalized convulsive epilepsy, without mention of intractable epilepsy345.11 Generalized convulsive epilepsy, with intractable epilepsy345.2 Petit mal status345.3 Grand mal status345.40 Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex
partial seizures, without mention of intractable epilepsy345.41 Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex
partial seizures, with intractable epilepsy345.50 Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial
seizures, without mention of intractable epilepsy345.51 Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial
seizures, with intractable epilepsy345.60 Infantile spasms, without mention of intractable epilepsy345.61 Infantile spasms, with intractable epilepsy345.70 Epilepsia partialis continua, without mention of intractable epilepsy345.71 Epilepsia partialis continua, with intractable epilepsy
8
345.80 Other forms of epilepsy and recurrent seizures, without mention of intractable epilepsy345.81 Other forms of epilepsy and recurrent seizures, with intractable epilepsy345.90 Epilepsy, unspecified, without mention of intractable epilepsy345.91 Epilepsy, unspecified, with intractable epilepsy356.2 Hereditary sensory neuropathy356.3 Refsum's disease356.4 Idiopathic progressive polyneuropathy356.8 Other specified idiopathic peripheral neuropathy356.9 Unspecified hereditary and idiopathic peripheral neuropathy357.0 Acute infective polyneuritis357.81 Chronic inflammatory demyelinating polyneuritis357.82 Critical illness polyneuropathy358.00 Myasthenia gravis without (acute) exacerbation358.01 Myasthenia gravis with (acute) exacerbation358.30 Lambert-Eaton syndrome, unspecified358.31 Lambert-Eaton syndrome in neoplastic disease358.39 Lambert-Eaton syndrome in other diseases classified elsewhere364.3 Unspecified iridocyclitis377.30 Optic neuritis, unspecified382.00 Acute suppurative otitis media without spontaneous rupture of eardrum382.01 Acute suppurative otitis media with spontaneous rupture of eardrum382.02 Acute suppurative otitis media in diseases classified elsewhere382.1 Chronic tubotympanic suppurative otitis media382.2 Chronic atticoantral suppurative otitis media382.3 Unspecified chronic suppurative otitis media382.4 Unspecified suppurative otitis media382.9 Unspecified otitis media425.4 Other primary cardiomyopathies446.1 Acute febrile mucocutaneous lymph node syndrome [MCLS]446.21 Goodpasture's syndrome446.4 Wegener's granulomatosis446.6 Thrombotic microangiopathy447.6 Arteritis, unspecified473.0 Chronic maxillary sinusitis473.1 Chronic frontal sinusitis473.2 Chronic ethmoidal sinusitis473.3 Chronic sphenoidal sinusitis473.8 Other chronic sinusitis473.9 Unspecified sinusitis (chronic)486 Pneumonia, organism unspecified493.00 Extrinsic asthma, unspecified493.01 Extrinsic asthma with status asthmaticus493.02 Extrinsic asthma with (acute) exacerbation493.10 Intrinsic asthma, unspecified493.11 Intrinsic asthma with status asthmaticus493.12 Intrinsic asthma with (acute) exacerbation493.20 Chronic obstructive asthma, unspecified493.21 Chronic obstructive asthma with status asthmaticus493.22 Chronic obstructive asthma with (acute) exacerbation493.81 Exercise induced bronchospasm493.82 Cough variant asthma493.90 Asthma,unspecified type, unspecified493.91 Asthma, unspecified type, with status asthmaticus
9
493.92 Asthma, unspecified type, with (acute) exacerbation530.81 Esophageal reflux629.81 Recurrent pregnancy loss without current pregnancy646.30 Recurrent pregnancy loss, unspecified as to episode of care or not applicable646.31 Recurrent pregnancy loss, delivered, with or without mention of antepartum condition646.33 Recurrent pregnancy loss, antepartum condition or complication694.4 Pemphigus694.5 Pemphigoid710.0 Systemic lupus erythematosus710.1 Systemic sclerosis710.3 Dermatomyositis710.4 Polymyositis714.0 Rheumatoid arthritis714.1 Felty's syndrome714.2 Other rheumatoid arthritis with visceral or systemic involvement714.30 Polyarticular juvenile rheumatoid arthritis, chronic or unspecified714.31 Polyarticular juvenile rheumatoid arthritis, acute714.32 Pauciarticular juvenile rheumatoid arthritis714.33 Monoarticular juvenile rheumatoid arthritis729.1 Myalgia and myositis, unspecified757.39 Other specified anomalies of skin780.71 Chronic fatigue syndrome996.80 Complications of transplanted organ, unspecified996.81 Complications of transplanted kidney996.82 Complications of transplanted liver996.83 Complications of transplanted heart996.84 Complications of transplanted lung996.85 Complications of transplanted bone marrow996.86 Complications of transplanted pancreas996.87 Complications of transplanted intestine996.88 Complications of transplanted organ, stem cell996.89 Complications of other specified transplanted organV08 Asymptomatic human immunodeficiency virus [HIV] infection statusV42.0 Kidney replaced by transplantV42.1 Heart replaced by transplantV42.6 Lung replaced by transplantV42.7 Liver replaced by transplantV42.83 Pancreas replaced by transplantV42.84 Organ or tissue replaced by transplant, intestinesV42.89 Other specified organ or tissue replaced by transplantV42.9 Unspecified organ or tissue replaced by transplant
Facility codingICD-9-CMprocedurecodes: Code Description99.14 Injection or infusion of immunoglobulin
ICD-10 Diagnosis CodesICD-10-CMDiagnosiscodes: Code DescriptionB20 Human immunodeficiency virus [HIV] disease
10
B25.0 Cytomegaloviral pneumonitis
B25.1 Cytomegaloviral hepatitis
B25.2 Cytomegaloviral pancreatitis
B25.8 Other cytomegaloviral diseases
B25.9 Cytomegaloviral disease, unspecified
C88.2 Heavy chain disease
C88.3 Immunoproliferative small intestinal disease
C88.8 Other malignant immunoproliferative diseases
E71.529 X-linked adrenoleukodystrophy, unspecified type
E71.53 Other group 2 peroxisomal disorders
E71.540 Rhizomelic chondrodysplasia punctata
E71.541 Zellweger-like syndrome
E71.542 Other group 3 peroxisomal disorders
E71.548 Other peroxisomal disorders
E84.0 Cystic fibrosis with pulmonary manifestations
E84.11 Meconium ileus in cystic fibrosis
E84.19 Cystic fibrosis with other intestinal manifestations
E84.8 Cystic fibrosis with other manifestations
E84.9 Cystic fibrosis, unspecified
G12.1 Other inherited spinal muscular atrophy
G12.21 Amyotrophic lateral sclerosis
G12.8 Other spinal muscular atrophies and related syndromes
G12.9 Spinal muscular atrophy, unspecified
G25.82 Stiff-man syndrome
G35 Multiple sclerosis
G40.001Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes withseizures of localized onset, not intractable, with status epilepticus
G40.009Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes withseizures of localized onset, not intractable, without status epilepticus
G40.011Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes withseizures of localized onset, intractable, with status epilepticus
G40.019Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes withseizures of localized onset, intractable, without status epilepticus
G40.101Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes withsimple partial seizures, not intractable, with status epilepticus
G40.109Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes withsimple partial seizures, not intractable, without status epilepticus
G40.111Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes withsimple partial seizures, intractable, with status epilepticus
G40.119 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with
17
simple partial seizures, intractable, without status epilepticus
G40.201Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes withcomplex partial seizures, not intractable, with status epilepticus
G40.209Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes withcomplex partial seizures, not intractable, without status epilepticus
G40.211Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes withcomplex partial seizures, intractable, with status epilepticus
G40.219Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes withcomplex partial seizures, intractable, without status epilepticus
G40.301Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with statusepilepticus
G40.309Generalized idiopathic epilepsy and epileptic syndromes, not intractable, without statusepilepticus
G40.311Generalized idiopathic epilepsy and epileptic syndromes, intractable, with statusepilepticus
G40.319Generalized idiopathic epilepsy and epileptic syndromes, intractable, without statusepilepticus
G40.401Other generalized epilepsy and epileptic syndromes, not intractable, with statusepilepticus
G40.409Other generalized epilepsy and epileptic syndromes, not intractable, without statusepilepticus
G40.411 Other generalized epilepsy and epileptic syndromes, intractable, with status epilepticus
G40.419Other generalized epilepsy and epileptic syndromes, intractable, without statusepilepticus
G40.501 Epileptic seizures related to external causes, not intractable, with status epilepticus
G40.509 Epileptic seizures related to external causes, not intractable, without status epilepticus
G40.801 Other epilepsy, not intractable, with status epilepticus
G40.802 Other epilepsy, not intractable, without status epilepticus
G40.803 Other epilepsy, intractable, with status epilepticus
G40.804 Other epilepsy, intractable, without status epilepticus
G40.811 Lennox-Gastaut syndrome, not intractable, with status epilepticus
G40.812 Lennox-Gastaut syndrome, not intractable, without status epilepticus
G40.813 Lennox-Gastaut syndrome, intractable, with status epilepticus
G40.814 Lennox-Gastaut syndrome, intractable, without status epilepticus
G40.821 Epileptic spasms, not intractable, with status epilepticus
G40.822 Epileptic spasms, not intractable, without status epilepticus
G40.823 Epileptic spasms, intractable, with status epilepticus
G40.824 Epileptic spasms, intractable, without status epilepticus
G40.89 Other seizures
G40.901 Epilepsy, unspecified, not intractable, with status epilepticus
G40.909 Epilepsy, unspecified, not intractable, without status epilepticus
G40.911 Epilepsy, unspecified, intractable, with status epilepticus
G40.919 Epilepsy, unspecified, intractable, without status epilepticus
G40.A01 Absence epileptic syndrome, not intractable, with status epilepticus
G40.A09 Absence epileptic syndrome, not intractable, without status epilepticus
G40.A11 Absence epileptic syndrome, intractable, with status epilepticus
G40.A19 Absence epileptic syndrome, intractable, without status epilepticus
G40.B01 Juvenile myoclonic epilepsy, not intractable, with status epilepticus
G40.B09 Juvenile myoclonic epilepsy, not intractable, without status epilepticus
G40.B11 Juvenile myoclonic epilepsy, intractable, with status epilepticus
G40.B19 Juvenile myoclonic epilepsy, intractable, without status epilepticus
G60.0 Hereditary motor and sensory neuropathy
18
G60.1 Refsum's disease
G60.3 Idiopathic progressive neuropathy
G60.8 Other hereditary and idiopathic neuropathies
G60.9 Hereditary and idiopathic neuropathy, unspecified
M31.30 Wegener's granulomatosis without renal involvement
M31.31 Wegener's granulomatosis with renal involvement
M32.0 Drug-induced systemic lupus erythematosus
M32.10 Systemic lupus erythematosus, organ or system involvement unspecified
M32.11 Endocarditis in systemic lupus erythematosus
M32.12 Pericarditis in systemic lupus erythematosus
M32.13 Lung involvement in systemic lupus erythematosus
M32.14 Glomerular disease in systemic lupus erythematosus
M32.15 Tubulo-interstitial nephropathy in systemic lupus erythematosus
M32.19 Other organ or system involvement in systemic lupus erythematosus
M32.8 Other forms of systemic lupus erythematosus
M32.9 Systemic lupus erythematosus, unspecified
M33.00 Juvenile dermatopolymyositis, organ involvement unspecified
M33.01 Juvenile dermatopolymyositis with respiratory involvement
M33.02 Juvenile dermatopolymyositis with myopathy
M33.09 Juvenile dermatopolymyositis with other organ involvement
M33.10 Other dermatopolymyositis, organ involvement unspecified
M33.11 Other dermatopolymyositis with respiratory involvement
M33.12 Other dermatopolymyositis with myopathy
M33.19 Other dermatopolymyositis with other organ involvement
M33.20 Polymyositis, organ involvement unspecified
M33.21 Polymyositis with respiratory involvement
M33.22 Polymyositis with myopathy
M33.29 Polymyositis with other organ involvement
M33.90 Dermatopolymyositis, unspecified, organ involvement unspecified
M33.91 Dermatopolymyositis, unspecified with respiratory involvement
M33.92 Dermatopolymyositis, unspecified with myopathy
M33.99 Dermatopolymyositis, unspecified with other organ involvement
M34.0 Progressive systemic sclerosis
M34.1 CR(E)ST syndrome
M34.2 Systemic sclerosis induced by drug and chemical
M34.81 Systemic sclerosis with lung involvement
M34.82 Systemic sclerosis with myopathy
M34.83 Systemic sclerosis with polyneuropathy
M34.89 Other systemic sclerosis
M34.9 Systemic sclerosis, unspecified
M35.2 Behçet's disease
M36.0 Dermato(poly)myositis in neoplastic disease
M60.80 Other myositis, unspecified site
M60.811 Other myositis, right shoulder
M60.812 Other myositis, left shoulder
M60.819 Other myositis, unspecified shoulder
M60.821 Other myositis, right upper arm
M60.822 Other myositis, left upper arm
M60.829 Other myositis, unspecified upper arm
M60.831 Other myositis, right forearm
M60.832 Other myositis, left forearm
M60.839 Other myositis, unspecified forearm
M60.841 Other myositis, right hand
M60.842 Other myositis, left hand
29
M60.849 Other myositis, unspecified hand
M60.851 Other myositis, right thigh
M60.852 Other myositis, left thigh
M60.859 Other myositis, unspecified thigh
M60.861 Other myositis, right lower leg
M60.862 Other myositis, left lower leg
M60.869 Other myositis, unspecified lower leg
M60.871 Other myositis, right ankle and foot
M60.872 Other myositis, left ankle and foot
M60.879 Other myositis, unspecified ankle and foot
M60.88 Other myositis, other site
M60.89 Other myositis, multiple sites
M60.9 Myositis, unspecified
M79.1 Myalgia
N96 Recurrent pregnancy loss
O26.20 Pregnancy care for patient with recurrent pregnancy loss, unspecified trimester
O26.21 Pregnancy care for patient with recurrent pregnancy loss, first trimester
O26.22 Pregnancy care for patient with recurrent pregnancy loss, second trimester
O26.23 Pregnancy care for patient with recurrent pregnancy loss, third trimester
Q81.0 Epidermolysis bullosa simplex
Q81.1 Epidermolysis bullosa letalis
Q81.2 Epidermolysis bullosa dystrophica
Q81.8 Other epidermolysis bullosa
Q81.9 Epidermolysis bullosa, unspecified
Q82.8 Other specified congenital malformations of skin
Q82.9 Congenital malformation of skin, unspecified
R53.82 Chronic fatigue, unspecified
T86.00 Unspecified complication of bone marrow transplant
T86.01 Bone marrow transplant rejection
T86.03 Bone marrow transplant infection
T86.09 Other complications of bone marrow transplant
T86.10 Unspecified complication of kidney transplant
T86.11 Kidney transplant rejection
T86.13 Kidney transplant infection
T86.19 Other complication of kidney transplant
T86.20 Unspecified complication of heart transplant
T86.21 Heart transplant rejection
T86.23 Heart transplant infection
T86.290 Cardiac allograft vasculopathy
T86.298 Other complications of heart transplant
T86.30 Unspecified complication of heart-lung transplant
T86.31 Heart-lung transplant rejection
T86.33 Heart-lung transplant infection
T86.39 Other complications of heart-lung transplant
T86.40 Unspecified complication of liver transplant
T86.41 Liver transplant rejection
T86.43 Liver transplant infection
T86.49 Other complications of liver transplant
T86.5 Complications of stem cell transplant
T86.810 Lung transplant rejection
T86.812 Lung transplant infection
30
T86.818 Other complications of lung transplant
T86.819 Unspecified complication of lung transplant
T86.830 Bone graft rejection
T86.831 Bone graft failure
T86.832 Bone graft infection
T86.838 Other complications of bone graft
T86.839 Unspecified complication of bone graft
T86.850 Intestine transplant rejection
T86.852 Intestine transplant infection
T86.858 Other complications of intestine transplant
T86.859 Unspecified complication of intestine transplant
T86.890 Other transplanted tissue rejection
T86.892 Other transplanted tissue infection
T86.898 Other complications of other transplanted tissue
T86.899 Unspecified complication of other transplanted tissue
T86.90 Unspecified complication of unspecified transplanted organ and tissue
T86.91 Unspecified transplanted organ and tissue rejection
T86.93 Unspecified transplanted organ and tissue infection
T86.99 Other complications of unspecified transplanted organ and tissue
Z21 Asymptomatic human immunodeficiency virus [HIV] infection status
Z48.21 Encounter for aftercare following heart transplant
Z48.22 Encounter for aftercare following kidney transplant
Z48.23 Encounter for aftercare following liver transplant
Z48.24 Encounter for aftercare following lung transplant
Z48.280 Encounter for aftercare following heart-lung transplant
Z48.288 Encounter for aftercare following multiple organ transplant
Z48.298 Encounter for aftercare following other organ transplant
Z94.0 Kidney transplant status
Z94.1 Heart transplant status
Z94.2 Lung transplant status
Z94.3 Heart and lungs transplant status
Z94.4 Liver transplant status
Z94.82 Intestine transplant status
Z94.83 Pancreas transplant status
Z94.89 Other transplanted organ and tissue status
Z94.9 Transplanted organ and tissue status, unspecified
Facility codingICD-9-CMprocedurecodes: Code Description99.14 Injection or infusion of immunoglobulin
Other Information
Preferred Home Infusion Therapy NetworkReferring providers are encouraged to use these preferred Home Infusion providers to obtain thesemedications.
Preferred Home Infusion Therapy Provider Contact Information:
31
Accredo Health Group
Phone: 1-877-988-0058
Website: www.accredo.com
Caremark, LLC.
Phone: 1-866-846-3096
Website: www.caremark.com
Coram™ Specialty Infusion Services
Phone: 1-800-678-3442
Website: www.coramhc.comHome Solutions
Falmouth Location:Phone: 1-508-548-4266 or toll free 1-800-244-1227
Canton Location:Phone: 1-617-989-0888 or toll free at 1-888-660-1660
Website: www.infusionreferral.com
Individual ConsiderationAll our medical policies are written for the majority of people with a given condition. Each policy is basedon medical science. For many of our medical policies, each individual’s unique clinical circumstancesmay be considered in light of current scientific literature. Physicians may send relevant clinical informationfor individual patients for consideration to:
Blue Cross Blue Shield of MassachusettsClinical Pharmacy DepartmentOne Enterprise DriveQuincy, MA 02171Tel: 1-800-366-7778Fax: 1-800-583-6289
Managed Care Authorization Instructions Prior authorization is required for all out patient sites of service For all outpatient sites of service, physicians may fax or mail the attached form to the address above For all outpatient sites of service, physicians may also submit authorization requests via the web
using Express PAth which can be found on the BCBSMA provider portal or directly on the web athttps://provider.express-path.com
PPO and Indemnity Authorization Instructions Prior authorization is required when this medication is processed under the home infusion therapy
benefit. Prior authorization is not required when this medication is purchased by the physician and
administered in the office in accordance with this medical policy. Physicians may also fax or mail the attached form to the address above. Physicians may also submit authorization requests via the web using Express PAth which can be
found on the BCBSMA provider portal or directly on the web at https://provider.express-path.com
Policy HistoryDate Action7/2014 Updated Coding section with ICD10 procedure and diagnosis codes, effective 10/2015.
1/2014 Updated ExpressPAth Language.1/2013 Updated 1/2013 to include new FDA products Gammaked™ and Gamunex®-C.11/2011-4/2012
Medical policy ICD 10 remediation: Formatting, editing and coding updates.No changes to policy statements.
1/2012 Reviewed - Medical Policy Group - Neurology and Neurosurgery.No changes to policy statements.
11/2011 Reviewed - Medical Policy Group - Plastic Surgery and Dermatology.No changes to policy statements.
10/2011 Reviewed - Medical Policy Group - Gastroenterology, Nutrition and OrganTransplantation.No changes to policy statements.
9/2011 Reviewed - Medical Policy Group - Urology and Obstetrics/Gynecology.No changes to policy statements.
1/2011 Reviewed - Medical Policy Group - Neurology and Neurosurgery.No changes to policy statements.
12/2010 Reviewed - Medical Policy Group - Plastic Surgery and Dermatology.No changes to policy statements.
11/2010 Reviewed - Medical Policy Group - Gastroenterology, Nutrition and OrganTransplantation.No changes to policy statements.
10/2010 Reviewed - Medical Policy Group - Urology and Obstetrics/Gynecology.No changes to policy statements.
9/2010 Reviewed - Medical Policy Group - Hematology and Oncology.No changes to policy statements.
1/2010 Reviewed - Medical Policy Group - Neurology and Neurosurgery.No changes to policy statements.
12/2009 Reviewed - Medical Policy Group - Plastic Surgery and Dermatology.No changes to policy statements.
11/2009 Reviewed - Medical Policy Group - Gastroenterology, Nutrition and OrganTransplantation.No changes to policy statements.
10/2009 Reviewed - Medical Policy Group - Urology and Obstetrics/Gynecology.No changes to policy statements.
9/2009 Reviewed - Medical Policy Group - Hematology and Oncology.No changes to policy statements.
10/2009 Updated to reflect UM requirements.1/2009 Reviewed - Medical Policy Group - Neurology and Neurosurgery.
No changes to policy statements.12/2008 Reviewed - Medical Policy Group - Plastic Surgery and Dermatology.
No changes to policy statements.11/2008 Reviewed - Medical Policy Group - Gastroenterology, Nutrition and Organ
Transplantation.No changes to policy statements.
10/2008 Reviewed - Medical Policy Group - Urology and Obstetrics/Gynecology.No changes to policy statements.
10/2008 Reviewed - Medical Policy Group - Hematology and Oncology.No changes to policy statements.
1/2008 Reviewed - Medical Policy Group - Neurology and Neurosurgery.No changes to policy statements.
9/2007 Reviewed - Medical Policy Group - Hematology and Oncology.No changes to policy statements.
1/2007 Reviewed - Medical Policy Group - Neurology and Neurosurgery.No changes to policy statements.
33
References1. van der Meche FG, Schmitz PI. A randomized trial comparing intravenous immune globulin and
plasma exchange in Guillain-Barre syndrome. N Engl J Med 1992; 326(17):1123-9.2. Plasma Exchange/Sandoglobulin Guillain-Barre Syndrome Trial Group. Randomised trial of plasma
exchange, intravenous immunoglobulin, and combined treatments in Guillain-Barre syndrome. Lancet1997; 349(9047):225-30.
3. Hahn AF, Bolton CF, Zochodne D et al. Intravenous immunoglobulin treatment in chronicinflammatory demyelinating polyneuropathy. A double-blind, placebo-controlled, cross-over study.Brain 1996; 119(pt 4):1067-77.
4. Sharma KR, Cross J, Ayyar DR et al. Diabetic demyelinating polyneuropathy responsive tointravenous immunoglobulin therapy. Arch Neurol 2002; 59(5):751-7.
5. Dyck PJ, Litchy WJ, Kratz KM et al. A plasma exchange versus immune globulin infusion trial inchronic inflammatory demyelinating polyradiculoneuropathy. Ann Neurol 1994; 36(6):838-45.
6. Dalakas MC, Quarles RH, Farrer RX et al. A controlled study of intravenous immunoglobulin indemyelinating neuropathy with IgM gammopathy. Ann Neurol 1996; 40(5):792-5.
7. Comi G, Roveri L, Swan A et al. A randomised controlled trial of intravenous immunoglobulin in IgMparaprotein associated with demyelinating neuropathy. J Neurol 2002; 249(10):1370-7.
8. Azulay JP, Blin O, Pouget J et al. Intravenous immunoglobulin treatment in patients with motorneuron syndromes associated with anti-GM1 antibodies: a double-blind, placebo-controlled study.Neurology 1994; 44(3 pt 1):429-32.
9. Leger JM, Chassande B, Musset L et al. Intravenous immunoglobulin therapy in multifocal motorneuropathy: a double-blind, placebo-controlled study. Brain 2001; 124(pt 1):145-53.
10. Federico P, Zochodne DW, Hahn AF et al. Multifocal motor neuropathy improved by IVIg:randomized, double-blind, placebo-controlled study. Neurology 2000; 55(9):1256-62.
11. Gajdos P, Chevret S, Clair B et al. Clinical trial of plasma exchange and high-dose intravenousimmunoglobulin in myasthenia gravis. Myasthenia Gravis Clinical Study Group. Ann Neurol 1997;41(6):789-96.
12. Qureshi AI, Choudhry MA, Akbar MS et al. Plasma exchange versus intravenous immunoglobulintreatment in myasthenic crisis. Neurology 1999; 52(3):629-32.
13. Ronager J, Ravnborg M, Hermansen I et al. Immunoglobulin treatment versus plasma exchange inpatients with chronic moderate to severe myasthenia gravis. Artif Organs 2001; 25(12):967-73.
14. Selcen D, Dabrowski ER, Michon AM et al. High-dose intravenous immunoglobulin therapy in juvenilemyasthenia gravis. Pediatr Neurol 2000; 22(1):40-3.
15. 1998 TEC Assessments; Tab 19.16. Goodin DS, Frohman EM, Garmany GP et al. Disease modifying therapies in multiple sclerosis.
Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy ofNeurology and the MS Council for Clinical Practice Guidelines. Neurology 2002; 58(2):169-78.
17. Dalakas MC, Illa I, Dambrosia JM et al. A controlled trial of high-dose intravenous immune globulininfusions as treatment for dermatomyositis. N Engl J Med 1993; 329(27):1993-2000.
18. Al-Mayouf SM, Laxer RM, Schneider R et al. Intravenous immunoglobulin therapy for juveniledermatomyositis: efficacy and safety. J Rheumatol 2000; 27(10):2498-503.
19. Gottfried I, Seeber A, Anegg B et al. High dose intravenous immunoglobulin (IVIG) indermatomyositis: clinical responses and effect on sIL-2R levels. Eur J Dermatol 2000; 10(1):29-35.
20. Cherin P, Pelletier S, Teixeira A et al. Results and long-term follow-up of intravenous immunoglobulininfusions in chronic, refractory polymyositis: an open study with thirty-five adult patients. ArthritisRheum 2002; 46(2):467-74.
21. Medicare coverage policy #CAG-00109N, 2002. Available online at: http://cms.hhs.gov/coverage/8b3-kkk.asp.
22. Bachot N, Revuz J Roujeau JC. Intravenous immunoglobulin treatment for Stevens-Johnsonsyndrome and toxic epidermal necolysis: a prospective noncomparative study showing no benefit onmortality or progression. Arch Dermatol 2003; 139(1):33-6.
23. Letko E, Miserocchi E, Daoud YJ et al. A nonrandomized comparison of the clinical outcome of ocularinvolvement in patients with mucous membrane (cicatricial) pemphigoid between conventionalimmunosuppressive and intravenous immunoglobulin therapies. Clin Immunol 2004; 111(3):303-10.
34
24. Dalakas MC, Sonies B, Dambrosia J et al. Treatment of inclusion-body myositis with IVIg: a double-blind, placebo-controlled study. Neurology 1997; 48(3):712-6.
25. Walter MC, Lochmuller H, Toepfer M et al. High-dose immunoglobulin therapy in sporadic inclusionbody myositis: a double-blind, placebo-controlled study. J Neurol 2000; 247(1):22-8.
26. Dalakas MC, Koffman B, Fujii M et al. A controlled study of intravenous immunoglobulin combinedwith prednisone in the treatment of IBM. Neurology 2001; 56(3):323-7.
27. Newburger JW, Takahashi M, Beiser AS et al. A single intravenous infusion of gamma globulincompared with four infusions in the treatment of acute Kawasaki syndrome. N Engl J Med 1991;324(23):1633-9.
28. Jayne DR, Chapel H, Adu D et al. Intravenous immunoglobulin for ANCA-associated systemicvasculitis with persistent disease activity. QJM 2000; 93(7):433-9.
29. Lockwood CM. New treatment strategies for systemic vasculitis: the role of intravenous immuneglobulin therapy. Clin Exp Immunol 1996; 104(suppl 1):77-82.
30. 1998 TEC Assessments; Tab 14.31. Bussel JB, Berkowitz RL, Lynch L et al. Antenatal management of alloimmune thrombocytopenia with
intravenous immunoglobulin: a randomized trial of the addition of low-dose steroid to intravenousgamma-globulin. Am J Obstet Gynecol 1996; 174(5):1414-23.
32. Kiehl MG, Stoll R, Broder M et al. A controlled trial of intravenous immune globulin for the preventionof serious infections in adults with advanced human immunodeficiency virus infection. Arch InternMed 1996; 156(22):2545-50.
33. Vollmer-Conna U, Hickie I, Hadzi-Pavlovic D et al. Intravenous immunoglobulin is ineffective in thetreatment of patients with chronic fatigue syndrome. Am J Med 1997; 103(1):38-43.
34. Kress HG, Scheidewig C, Schmidt H et al. Reduced incidence of postoperative infection afterintravenous administration of an immunoglobulin A- and immunoglobulin M-enriched preparation inanergic patients undergoing cardiac surgery. Crit Care Med 1999; 27(7):1281-7.
35. Douzinas EE, Pitaridis MT, Louris G et al. Prevention of infection in multiple trauma patients by high-dose intravenous immunoglobulins. Crit Care Med 2000; 28(1):8-15.
36. Voss LM, Wilson NJ, Neutze JM et al. Intravenous immunoglobulin in acute rheumatic fever: arandomized controlled trial. Circulation 2001; 103(3):401-6.
38. Hundt M, Manger K, Dorner T et al. Treatment of acute exacerbation of systemic lupuserythematosus with high-dose intravenous immunoglobulin. Rheumatology (Oxford) 2000;39(11):1301-2.
39. Levy Y, Sherer Y, Ahmed A et al. A study of 20 SLE patients with intravenous immunoglobulin--clinical and serologic response. Lupus 1999; 8(9):705-12.
40. Boletis JN, Ioannidis JP, Boki KA et al. Intravenous immunoglobulin compared withcyclophosphamide for proliferative lupus nephritis. Lancet 1999; 354(9178):569-70.
41. Casadei DH, del C Rial M, Opelz G et al. A randomized and prospective study comparing treatmentwith high-dose intravenous immunoglobulin with monoclonal antibodies for rescue of kidney graftswith steroid-resistant rejection. Transplantation 2001; 71(1):53-8.
42. Luke PP, Scantlebury VP, Jordan ML et al. Reversal of steroid- and anti-lymphocyte antibody-resistant rejection using intravenous immunoglobulin (IVIG) in renal transplant recipients.Transplantation 2001; 72(3):419-22.
43. Jordan SC, Quartel AW, Czer LS et al. Posttransplant therapy using high-dose humanimmunoglobulin (intravenous gammaglobulin) to control acute humoral rejection in renal and cardiacallograft recipients and potential mechanism of action. Transplantation 1998; 66(6):800-5.
44. LeHoang P, Cassoux N, George F et al. Intravenous immunoglobulin (IVIg) for the treatment ofbirdshot retinochoroidopathy. Ocul Immunol Inflamm 2000; 8(1):49-57.
45. Rosenbaum JT, George RK, Gordon C. The treatment of refractory uveitis with intravenousimmunoglobulin. Am J Ophthalmol 1999; 127(5):545-9.
46. Noseworthy JH, O'Brien PC, Petterson TM et al. A randomized trial of intravenous immunoglobulin ininflammatory demyelinating optic neuritis. Neurology 2001; 56(11):1514-22.
47. Kishiyama JL, Valacer D, Cunningham-Rundles C et al. A multicenter, randomized, double-blind,placebo-controlled trial of high-dose intravenous immunoglobulin for oral corticosteroid-dependentasthma. Clin Immunol 1999; 91(2):126-33.
35
48. Salmun LM, Barlan I, Wolf HM et al. Effect of intravenous immunoglobulin on steroid consumption inpatients with severe asthma: a double-blind, placebo-controlled, randomized trial. J Allergy ClinImmunol 1999; 103(5 pt 1):810-5.
49. Sullivan KM, Kopecky KJ, Jocom J et al. Immunoglobulin and antimicrobial efficacy of intravenousimmunoglobulin in bone marrow transplantation. N Engl J Med 1990; 323(11):705-12.
50. Bass EB, Powe NR, Goodman SN et al. Efficacy of immune globulin in preventing complications ofbone marrow transplantation: a meta-analysis. Bone Marrow Transplant 1993; 12(3):273-82.
51. Guglielmo BJ, Wong-Beringer A, Linker CA. Immune globulin therapy in allogeneic bone marrowtransplant: a critical review. Bone Marrow Transplant 1994; 13(5):499-510.
52. American Society of Reproductive Medicine. Intravenous Immunoglobulin (IVIG) and RecurrentSpontaneous Pregnancy Loss: A Practice Committee Report; A Committee Opinion. 1998. Availableat http://www.asrm.org/Media/Practice/ivig.html. Accessed October 2002.
53. Scott JR. Immunotherapy for recurrent miscarriage (Cochrane Review). In: The Cochrane Library,Issue 3, 2002. Oxford: Update Software.
54. Jablonowska B, Selbing A, Palfi M et al. Prevention of recurrent spontaneous abortion by intravenousimmunoglobulin: a double-blind placebo-controlled study. Hum Reprod 1999; 14(3):838-41.
55. Branch DW, Peaceman AM, Druzin M et al. A multicenter, placebo-controlled pilot study ofintravenous immune globulin treatment of antiphospholipid syndrome during pregnancy. ThePregnancy Loss Study Group. Am J Obstet Gynecol 2000; 182(1 Pt 1):122-7.
56. Christiansen OB, Pedersen B, Rosgaard A et al. A randomized, double-blind, placebo-controlled trialof intravenous immunoglobulin in the prevention of recurrent miscarriage: evidence for a therapeuticeffect in women with secondary recurrent miscarriage. Hum Reprod 2002; 17(3):809-16.
57. Cordonnier C, Chevret S, Legrand M et al. Should immunoglobulin therapy be used in allogeneicstem-cell transplantation? A randomized, double-blind, dose effect, placebo-controlled multicentertrial. Ann Intern Med 2003; 139(1):8-18.
58. Jordan SC, Tyan D, Stablein D et al. Evaluation of intravenous immunoglobulin as an agent to lowerallosensitization and improve transplantation in highly sensitized adult patients with end-stage renaldisease: report of the NIH IG02 trial. J Am Soc Nephrol 2004; 15(12):3256-62.
59. Jordan SC, Vo AA, Nast CC et al. Use of high-dose human intravenous immunoglobulin therapy insensitized patients awaiting transplantation: the Cedars-Sinai experience. Clin Transpl 2003; 193-8.
60. MontgomeryRA, Zachary AA. Transplanting patients with a positive donor-specific crossmatch: asingle center’s perspective. Pediatr Transplant 2004; 8(6):535-42.
61. Jordan SC, Vo AA, Tyan D et al. Current approaches to treatment of antibody-mediated rejection.Pediatr Transplant 2005; 9(3):408-15.
62. Lehrich RW, Rocha PN, Reinsmoen N et al. Intravenous immunoglobulin and plasmapheresis inacute humoral rejection: Experience in renal allograft transplantation. Hum Immunol 2005; 66(4):350-8.
63. Casadei DH, del C Rial M, Opelz G et al. A randomized and prospective study comparing treatmentwith high-dose intravenous immunoglobulin with monoclonal antibodies for rescue of kidney graftswith steroid-resistant rejection. Transplantation 2001; 71(1):53-8.
64. Ibernon M, Gil-Vernet S, Carrera M et al. Therapy with plasmapheresis and intravenousimmunoglobulin for acute humoral rejection in kidney transplantation. Transplant Proc 2005;37(9):3743-5.
Endnotes1. Revised 9/95 based on TEC (Technology Evaluation Center) 6/95 assessment of medical literature
from 1991 to 1995 addressing IVIg for SLE-related cytopenia, vasculitis, pericarditis, and pleuraleffusions in patients who were not controlled by immunosuppressives or cytotoxic agents.
2. Revised 9/95 to include the 2/95 TEC evaluation of medical literature from 1991-4/95 assessing IVIgto improve the functional status of patients with inclusion body myositis who have not responded toprednisone or other immunosuppressives.
3. Revised 10/95 based on 1994 TEC evaluation of medical literature from 1991-1994 assessing IVIG tostop progression of muscle weakness or to decrease frequency or severity of relapses in MS..
36
4. Revised 10/95 based on a 1994 TEC evaluation of medical literature from 1991-1994 assessing IVIgto improve functional capacity or to reduce pain in patients with RA refractory to NSAIDS and eithercytotoxic or disease-modifying antirheumatic drugs.
5. Revised 10/95 based on a 1994 TEC evaluation of medical literature from 1991-1994 assessing IVIGto improve neurologic function in CIDP, either as first-line therapy, or for acute exacerbations inpatients refractory or intolerant of prednisone or azathioprine.
6. Revised 10/95 based on a 1994 TEC evaluation of medical literature assessing IVIG to reduce fetalloss in women with recurrent fetal loss (sequence of 3 or more miscarriages), with or withoutantiphospholipid antibodies.
7. Revised 3/96 to include CMS (Centers for Medicare and Medicaid services) regulations published inthe February/March 1996 issue of the Medicare Health Resources.
8. Revised 2/97 to include CMS (Centers for Medicare and Medicaid services) regulations published inthe February/March 1997 issue of the Medicare Health Resources.
9. Revised 9/97 to include CMS regulations (Centers for Medicare and Medicaid services) published inthe June/July 1997 Medicare B Health Resources.
10. Added based on recommendations made by the Massachusetts Neurological Society.11. Based on the July 1998 TEC (Technology Evaluation Center) analysis of the literature on IVIg for
MS. Health outcomes considered by TEC included prevention of disease progress and disability,improving baseline neuro disability, and reducing acute relapse.Also see the July/August 1997 ACP Journal Club commentary:http://www.acponline.org/journals/acpjc/julaug97Regarding the article: Fazekas F et al., Austrian Immunoglobulin in Multiple Sclerosis Study Group.Randomized placebo-controlled trial of monthly intravenous immunoglobulin therapy in relapsing-remitting multiple sclerosis. Lancet. 1997 Mar 1;349:589-93.
12. FDA-approved uses as of July, 1998.13. Off-label use in the treatment of AIDS and HIV as required by law.14. Label use based on National Blue Cross Blue Shield policy 8.01.05, issued 12/15/98.15. Off-label use based on National Blue Cross Blue Shield policy 8.01.05, issued 12/15/98.16. Investigational use based on National Blue Cross Blue Shield policy 8.01.05, issued 12/15/98.17. Based on recommendations from Walt Kagan, MD, Massachusetts Society of Clinical Oncologists.18. Based upon a September 1999 Medicare B HealthResource Newsletter.19. Medicare policy is developed separately from BCBSMA policy. While BCBSMA policy is based upon
scientific evidence, Medicare policy incorporates scientific evidence with local expert opinion, andgovernmental regulations from CMS (Centers for Medicare and Medicaid Services) and the U.SCongress. While BCBSMA and Medicare policies may differ, our Medicare HMO Blue and MedicarePPO Blue members must be offered the same services as Medicare offers. In many instances,BCBSMA policies offer more benefits than does Medicare policy.
20. Based on recommendations from David Weinberg, MD, Massachusetts Neurologic Association,1/2000 MPG Neurology meeting.
21. Medical Policy Group, August 2000.22. Previous criteria summarized in the current form: vital capacity less than 1L; dysphagia associated
with aspiration; inability to ambulate 100 feet without assistance.23. Medical Policy Group, January 2000.24. Idiopathic Thrombocytopenic Purpura: A Practice Guideline Developed by Explicit Methods for the
American Society of Hematology25. See the 1998 ASRM (American Society of Reproductive Medicine) Practice Committee Report on
Intravenous Immunoglobulin and Spontaneous Pregnancy Loss.26. Based on the June 2002 Medicare B Resource Newsletter. See also the CMS /Medicare websites at
www.cms.gov and www medicare.gov.27. Based upon the 2002 Blue Cross Blue Shield Association policy 8.01.05. IVIG for myasthenic crisis
is considered medically necessary. Myasthenic crisis is an off-label indication.28. Based upon the 2002 Blue Cross Blue Shield Association National policy 8.01.05.29. Based upon the 2004 Blue Cross Blue Shield Association policy 2.01.01.30. Based upon the 2004 Blue Cross Blue Shield Association National policy 8.01.05.31. Consensus statement on the use of intravenous immunoglobulin therapy in the treatment of
32. Based upon the 2004 BCBSA National Policy 8.01.05. Bone marrow transplant patients (forprevention of infection or GVH prevention.) Cordonnier C, Chevret S, Legrand M et al. Should immunoglobulin therapy be used in allogeneic
stem-cell transplantation? A randomized, double-blind, dose effect, placebo-controlled multicentertrial. Ann Intern Med 2003;139(1):8-18.
33. Based upon the 2004 BCBSA National Policy 8.01.05. Recurrent Spontanous Abortion.34. Based on Blue Cross Blue Shield National policy 8.01.05 Intravenous Immune Globulin Therapy
issued 4/06.
38
Home Infusion TherapyPrior Authorization Form
Please complete and fax with the physician's prescription to: (888) 641-5355. If the patient is aBCBSMA employee, please fax the form to: (617)246-4013.
Is this fax number ‘secure’ for PHI receipt/transmission per HIPAA requirements? (circle one) Yes No
Place of Service Home SNF MD office other (specify)_____________________Primary Therapy
Primary drugname:
Approximateduration:
____/____/____ to____/____/____
Dose:
Frequency: Route of Administration: pump: Y N
Other Therapy
Other drug name: Approximateduration:
____/____/____ to____/____/____
Dose:
Frequency Route of Administration: pump: Y N
If this is a “drug only” authorization request, indicate other services the nursing agency is providing:
______________________________________________________________________________________Nursing provided by: ________________________________ Contact: _________________________Phone: ______________ Fax: ___________________Request for 7 Day Coverage : Date of occurrence: ___________ request dates:___________________
Occurrence type: Hospitalization Death Change of Therapy