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Immune Globulins (immunoglobulin): Alyglo™; Bivigam®; Flebogamma®; Gamunex-C®; Gammagard® Liquid; Gammagard® S/D; Gammaked™; Gammaplex®; Octagam®; Privigen®; Panzyga®
Policy Number: PH-0071
Intravenous
Last Review Date: 07/02/2024
Date of Origin: 07/20/2010
Dates Reviewed: 09/2010, 12/2010, 02/2011, 03/2011, 06/2011, 09/2011, 10/2011, 12/2011, 03/2012, 06/2012, 09/2012, 12/2012, 03/2013, 05/2013, 06/2013, 09/2013, 12/2013, 03/2014, 06/2014, 09/2014, 12/2014, 03/2015, 06/2015, 09/2015, 12/2015, 03/2016, 06/2016, 09/2016, 12/2016, 03/2017, 06/2017, 09/2017, 12/2017, 03/2018, 06/2018, 09/2018, 10/2018, 05/2019, 10/2019, 10/2020, 01/2021, 04/2021, 10/2021, 11/2022, 11/2023, 02/2024, 07/2024
FOR PEEHIP Members Only -Coverage excludes the provider-administered medication(s) outlined in this drug policy from being accessed through a specialty pharmacy. It must be obtained through buy and bill. |
- Length of Authorization
- Initial and renewal authorization periods vary by specific covered indication.
- Unless otherwise specified, the initial authorization will be provided for 6 months and may be renewed annually.
- Dosing Limits
- Quantity Limit (max daily dose) [NDC Unit]:
Drug
Vial size in IgG grams
# of vials
One time only
per 28 days
LOAD
MAINTENANCE
Alyglo
5, 10, 20
1
1
Bivigam
5
1
1
10
23
23
Flebogamma 10% DIF
5, 10, 20
1
1
20
11
11
Flebogamma 5% DIF
0.5, 2.5, 5, 10
1
1
20
11
11
Gamunex-C
1, 2.5, 5, 10, 20
1
1
40
6
6
Gammagard Liquid
1, 2.5, 5, 10, 20
1
1
30
8
8
Gammagard S/D
5
1
1
10
23
23
Gammaked
1, 2.5, 5, 10
1
1
20
11
11
Gammaplex (5% and 10%)
5, 10
1
1
20
11
11
Octagam 10%
2, 5, 10, 20
1
1
30
8
8
Octagam 5%
1, 2.5, 5, 10
1
1
25
9
9
Privigen
5, 10, 20
1
1
40
6
6
Panzyga
1, 2.5, 5, 10, 20
1
1
30
8
8
Yimmugo
5, 10, 20
1
1
- Max Units (per dose and over time) [HCPCS Unit]:
Indication |
Billable Units |
Per # days (unless otherwise specified) |
PID and Supportive Care after Rethymic transplant |
180 |
21 |
IgG Subclass Deficiency |
90 |
14 |
CIDP |
Load: 460 |
5 |
Maintenance: 230 |
21 |
|
Immune thrombocytopenia/ITP |
460 |
28 |
FAIT |
230 |
7 |
Kawasaki’s Disease |
460 |
2 doses only |
Multifocal Motor Neuropathy |
460 |
28 |
CLL/MM |
90 |
21 |
ALL |
90 |
21 |
HIV (Pediatric Patients only) |
46 |
14 |
Guillain-Barré |
460 |
5 (for two courses only) |
Myasthenia Gravis |
460 |
28 |
Auto-immune blistering diseases |
460 |
28 |
Allogeneic Bone Marrow or Stem Cell Transplant
|
Load: 120 |
7 (for 90 days) |
Maintenance: 120 |
21 |
|
Dermatomyositis/Polymyositis |
460 |
28 |
Complications of transplanted solid organ or bone marrow transplant |
460 |
28 |
Stiff Person Syndrome |
460 |
28 |
Toxic Shock Syndrome |
460 |
5 (for one cycle only) |
NAIT |
20 |
2 doses only |
Management of Immune Checkpoint Inhibitor Related Toxicity |
460 |
5 (for one cycle only) |
Management of CAR T-Cell-Related Toxicity |
120 |
28 |
- Initial Approval Criteria 1-16,71
Depending on member benefits, additional criteria may apply for coverage of this drug in an outpatient facility setting. Verify any Site of Service requirements with the member’s plan and refer to the Voluntary Site of Service Policy or the Mandatory Site of Service Policy for additional information. |
Coverage is provided for the following conditions:
For Commercial Members Only |
Treatment with Asceniv is considered excluded from coverage, unless the patient is continuing therapy with Asceniv |
For PEEHIP Members Only |
1. Preferred: Gammagard, Gammaked, Gamunex-C, Privigen 2. Non-preferred: Gammagard SD, Gammaplex, Octagam 3. Non-covered: Asceniv, Bivigam, Flebogamma, Panzyga, Alyglo
|
- Baseline values for BUN and serum creatinine obtained within 30 days of request; AND
Primary Immunodeficiency (PID) † 1-16,38,54,56,57,70,103
Such as: Wiskott-Aldrich syndrome, x-linked agammaglobulinemia, common variable immunodeficiency, transient hypogammaglobulinemia of infancy, antibody deficiency with near normal immunoglobulin levels, and combined deficiencies (severe combined immunodeficiencies, ataxia-telangiectasia, x-linked lymphoproliferative syndrome) [list not all inclusive]
- Patient has an IgG level < 200 mg/dL; OR
- Patient meets both of the following:
- Patient has a history of multiple hard to treat infections as indicated by at least one of the following:
- Four or more ear infections within 1 year
- Two or more serious sinus infections within 1 year
- Two or more months of antibiotics with little effect
- Two or more pneumonias within 1 year
- Recurrent, deep skin or organ abscesses
- Persistent thrush in the mouth or fungal infections on the skin
- Need for intravenous antibiotics to clear infections
- Two or more deep-seated infections including septicemia
- Family history of PID; AND
- Patient has a deficiency in producing antibodies in response to vaccination; AND
- Titers were drawn before challenging with vaccination; AND
- Titers were drawn between 4 and 8 weeks of vaccination
IgG Subclass Deficiency ‡ 57,70,98-100
- Patient has an IgG level < 400 mg/dL; AND
- Patient has a history of recurrent infections; AND
- Patient is receiving prophylactic antibiotic therapy
Immune Thrombocytopenia/Idiopathic Thrombocytopenia Purpura (ITP) † (Ф for Gammaplex) 2,5-9,11-13,32,37,39,81
For acute ITP:
- Used to manage acute bleeding due to severe thrombocytopenia (platelet count < 30 X 109/L); OR
- Used to increase platelet counts prior to invasive surgical procedures such as splenectomy (platelet count < 100 X 109/L); OR
- Patient has severe thrombocytopenia (platelet count < 20 X 109/L)
Note: Authorization is valid for 1 month only and cannot be renewed
For chronic ITP:
- Patient is at increased risk for bleeding as indicated by a platelet count < 30 X 109/L; AND
- Patient has a history of failure, contraindication, or intolerance to corticosteroids; AND
- Duration of illness > 6 months
Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) † (Ф for Gamunex-C) 4,6,7,12,13,18-22,24-26,42,44,72,116
- Patient’s disease course is progressive or relapsing and remitting for >2 months; AND
- Patient has abnormal or absent deep tendon reflexes in upper or lower limbs; AND
- Electrodiagnostic testing indicating demyelination:
- Partial motor conduction block in at least 2 motor nerves or in 1 nerve plus one other demyelination criterion listed here in at least 1 other nerve; OR
- Distal CMAP duration increase in at least 1 nerve plus one other demyelination criterion listed here in at least 1 other nerve; OR
- Abnormal temporal dispersion conduction must be present in at least 2 motor nerves; OR
- Reduced motor conduction velocity in at least 2 motor nerves; OR
- Prolonged distal motor latency in at least 2 motor nerves; OR
- Absent F wave in at least 2 motor nerves plus one other demyelination criterion listed here in at least 1 other nerve; OR
- Prolonged F wave latency in at least 2 motor nerves; AND
- Patient is refractory or intolerant to corticosteroids (e.g., prednisolone, prednisone, etc.) given in therapeutic doses over at least three months; AND
- Baseline in strength/weakness has been documented using an objective clinical measuring tool (e.g., INCAT, Medical Research Council (MRC) muscle strength, 6-MWT, Rankin, Modified Rankin, etc.)
Note: Initial authorization is valid for 3 months
Guillain-Barré Syndrome (Acute inflammatory polyneuropathy) ‡ 19,21,22,24,30,31,58,70,77,115
- Patient has severe disease (i.e., patient requires assistance to ambulate); AND
- Onset of symptoms are recent (i.e., less than 1 month); AND
- Patient has abnormal or absent deep tendon reflexes in upper or lower limbs; AND
- Patient diagnosis is confirmed using a cerebrospinal fluid (CSF) analysis; AND
- Approval will be granted for a maximum of 2 courses of therapy within 6 weeks of onset
Note: Authorization is valid for 2 months only and cannot be renewed
Multifocal Motor Neuropathy † (Ф for Gammagard Liquid) 4,19,21,22,24,25
- Patient has progressive, focal, asymmetric limb weakness (without sensory symptoms) for >1 month; AND
- Patient has complete or partial conduction block or abnormal temporal dispersion conduction in at least 2 motor nerves; AND
- Patient has normal sensory nerve conduction on all nerves tested; AND
- Baseline in strength/weakness has been documented using an objective clinical measuring tool (e.g., INCAT, Medical Research Council (MRC) muscle strength, 6-MWT, Rankin, Modified Rankin, etc.)
Note: Initial authorization is valid for 3 months
HIV Infected Children: Bacterial Control or Prevention ‡ 27,28,37,89
- Patient < 13 years of age; AND
- Patient has an IgG level < 400 mg/dL
Myasthenia Gravis ‡ 53,78,85
- Patient has a positive serologic test for anti-acetylcholine receptor (AchR) antibodies; AND
- Patient has an acute exacerbation resulting in impending myasthenic crisis (i.e., respiratory compromise, acute respiratory failure, and/or bulbar compromise); AND
- Patient is failing on conventional immunosuppressant therapy alone (e.g., corticosteroids, azathioprine, cyclosporine, mycophenolate, methotrexate, tacrolimus, cyclophosphamide, etc.); AND
- Patient will be on combination therapy with corticosteroids or other immunosuppressant (e.g., azathioprine, mycophenolate, cyclosporine, methotrexate, tacrolimus, cyclophosphamide, etc.)
Note: Authorization is valid for 1 course (1 month) only and cannot be renewed
Dermatomyositis † (Ф for Octagam 10%) / Polymyositis ‡ 11,19,21,22,24,65,66,70,82,87
- Patient has severe active disease; AND
- Patient has proximal weakness in all upper and/or lower limbs; AND
- Diagnosis has been confirmed by muscle biopsy; AND
- Patient has failed a trial of corticosteroids (i.e., prednisone); AND
- Patient has failed a trial of an immunosuppressant (e.g., methotrexate, azathioprine, etc.); AND
- Patient will be on combination therapy with corticosteroids or other immunosuppressants; AND
- Patient has a documented baseline physical exam and muscular strength/function
Note: Initial authorization is valid for 3 months
Complications of Transplanted Solid Organ (kidney, liver, lung, heart, pancreas) and Bone Marrow Transplant ‡ 59-62,70,102
Coverage is provided for one or more of the following (list not all-inclusive):
- Suppression of panel reactive anti-human leukocyte antigen (HLA) antibodies prior to transplantation
- Treatment of antibody-mediated rejection of solid organ transplantation
- Prevention or treatment of viral infections (e.g., cytomegalovirus, Parvo B-19 virus, Polyoma BK virus, etc.)
Stiff-Person Syndrome ‡ 21,24,64,114
- Patient has anti-glutamic acid decarboxylase (GAD) antibodies; AND
- Patient has failed > 2 of the following treatments: benzodiazepines (e.g., diazepam, clonazepam, alprazolam, lorazepam, oxazepam, temazepam, etc.), anti-spasticity agents (e.g., baclofen, tizanidine, etc.) or anti-epileptics (e.g., gabapentin, valproate, tiagabine, levetiracetam, etc.); AND
- Patient has a documented baseline on physical exam
Allogeneic Bone Marrow or Stem Cell Transplant ‡ 76,102,113
- Used for prevention of acute Graft-Versus-Host-Disease (aGVHD) or infection; AND
- Patient’s bone marrow (BMT) or hematopoietic stem cell (HSCT) transplant was allogeneic; AND
- Patient has an IgG level < 400 mg/dL
Note: Initial authorization is valid for 3 months
Kawasaki’s Disease † 5,83
Note: Authorization is valid for 1 course (1 month) only and cannot be renewed
Fetal Alloimmune Thrombocytopenia (FAIT) ‡ 32,37,47,84,90
- Patient has a history of one or more of the following:
- Previous FAIT pregnancy
- Family history of the disease
- Screening reveals platelet alloantibodies
Note: Authorization is valid through the delivery date only and cannot be renewed
Neonatal Alloimmune Thrombocytopenia (NAIT) ‡ 35-37,84
Note: Authorization is valid for 1 course (1 month) only and cannot be renewed
Autoimmune Mucocutaneous Blistering Diseases ‡ 34,40,41,67-69,91,110-112
- Patient has been diagnosed with one of the following:
- Pemphigus vulgaris
- Pemphigus foliaceus
- Bullous Pemphigoid
- Mucous Membrane Pemphigoid (a.k.a. Cicatricial Pemphigoid)
- Epidermolysis bullosa aquisita
- Pemphigus gestationis (Herpes gestationis)
- Linear IgA dermatosis; AND
- Patient has severe disease that is extensive and debilitating; AND
- Diagnosis has been confirmed by biopsy; AND
- Patient has progressive disease; AND
- Disease is refractory to a trial of conventional therapy with corticosteroids and concurrent immunosuppressive treatment (e.g., azathioprine, cyclophosphamide, mycophenolate mofetil, etc.); AND
- Patient has a documented baseline on physical exam
Acquired Immune Deficiency Secondary to Acute Lymphoblastic Leukemia (ALL) ‡ or Multiple Myeloma ‡ 37,70,79,92,106
- Used for prevention of infection; AND
- Patient has an IgG level < 400 mg/dL
Acquired Immune Deficiency Secondary to Chronic Lymphocytic Leukemia † ‡ or Small Lymphocytic Lymphoma ‡ 5,37,70,88,103,107
- Patient has an IgG level < 200 mg/dL; OR
- Patient has an IgG level < 500 mg/dL; AND
- Patient has recurrent sinopulmonary infections requiring IV antibiotics or hospitalization; OR
- Patient has a history of multiple hard to treat infections as indicated by at least one of the following:
-
-
- Four or more ear infections within 1 year
- Two or more serious sinus infections within 1 year
- Two or more months of antibiotics with little effect
- Two or more pneumonias within 1 year
- Recurrent, deep skin or organ abscesses
- Persistent thrush in the mouth or fungal infections on the skin
- Need for intravenous antibiotics to clear infections
- Two or more deep-seated infections including septicemia
-
-
Note: Other secondary immunodeficiencies resulting in hypogammaglobulinemia and/or B-cell aplasia will be evaluated on a case-by-case basis
Toxic Shock Syndrome ‡ 46,93,94
Note: Authorization is valid for 1 course (1 month) only and cannot be renewed
Management of Immune-Checkpoint-Inhibitor Related Toxicity ‡ 73,80
- Patient has been receiving therapy with an immune checkpoint inhibitor (e.g., nivolumab, pembrolizumab, atezolizumab, avelumab, durvalumab, cemiplimab, ipilimumab, dostarlimab, tremelimumab, retifanlimab, etc.); AND
- Patient has one of the following toxicities related to their immunotherapy:
- Severe (G3) or life-threatening (G4) bullous dermatitis as an adjunct to rituximab
- Stevens-Johnson syndrome (SJS)
- Toxic epidermal necrolysis (TEN)
- Severe (G3-4) myasthenia gravis
- Demyelinating disease (optic neuritis, transverse myelitis, acute demyelinating encephalomyelitis)
- Myocarditis as further intervention if no improvement within 24-48 hours of starting high-dose methylprednisolone
- Moderate (G2) or severe (G3-4) Guillain-Barré Syndrome or severe (G3-4) peripheral neuropathy used in combination with high-dose methylprednisolone
- Moderate (G2) pneumonitis if no improvement after 48-72 hours of corticosteroids
- Severe (G3-4) pneumonitis if no improvement after 48 hours of methylprednisolone
- Encephalitis used in combination with high-dose methylprednisolone for severe or progressing symptoms
- Moderate, severe, or life-threatening steroid-refractory myositis (proximal muscle weakness, neck flexor weakness, with or without myalgias) for significant dysphagia, life-threatening situations, or cases refractory to corticosteroids
Management of CAR T-Cell-Related Toxicity ‡ 73,80,86,95,96,104,105
- Patient has received treatment with anti-CD19 CAR T-cell therapy (e.g., axicabtagene ciloleucel, brexucabtagene autoleucel, lisocabtagene maraleucel, tisagenlecleucel, etc.); AND
- Used for the management of G4 cytokine release syndrome (CRS) that is refractory to high-dose corticosteroids and anti-IL-6 therapy (e.g., tocilizumab); OR
- Patient has hypogammaglobulinemia as confirmed by serum IgG levels <600 mg/dL and serious or recurrent infections; OR
- Patient has received treatment with BCMA-targeted CAR T-cell therapy (e.g., idecabtagene vicleucel, ciltacabtagene autoleucel, etc.); AND
- Used for the management of G4 cytokine release syndrome (CRS) that is refractory to high-dose corticosteroids and anti-IL-6 therapy (e.g., tocilizumab); OR
- Patient has hypogammaglobulinemia as confirmed by serum IgG levels <400 mg/dL; OR
- Used as prophylactic therapy prior to receiving treatment with anti-CD19 or BCMA-targeted CAR T-cell therapy (e.g., axicabtagene ciloleucel, brexucabtagene autoleucel, idecabtagene vicleucel, lisocabtagene maraleucel, tisagenlecleucel, ciltacabtagene autoleucel, etc.); AND
- Patient has hypogammaglobulinemia as confirmed by serum IgG levels ≤400 mg/dL and serious, persistent, or recurrent bacterial infections
Supportive Care after Rethymic transplant ‡ 97
- Used as immunoglobulin replacement therapy in pediatric patients with congenital athymia after surgical implantation of Rethymic; OR
- Used as re-initiation of treatment 2 months after stopping immunoglobulin replacement therapy in pediatric patients who have an IgG trough level lower than normal range for age
† FDA Approved Indication(s); ‡ Compendia Recommended Indication(s); Ф Orphan Drug
*For Reference Use Only |
||||
|
||||
Brand Name/ Formulation |
FDA Indication |
Contraindications |
Product Specs |
Comments |
Alyglo 10% |
PID (adults) |
History of anaphylaxis to IgG IgA-deficient with IgA antibodies |
|
|
Bivigam 10% (liquid) |
PID (peds ≥2) |
History of anaphylaxis to IgG IgA-deficient with IgA antibodies |
|
|
Flebogamma 5% (liquid) |
PID (peds ≥2) |
History of anaphylaxis to IgG IgA-deficient with IgA antibodies |
IgA: <50 mcg/mL Osmolarity: 240 to 370 mOsm/kg Stabilizer: sorbitol |
|
Flebogamma 10% (liquid) |
PID (peds ≥2) cITP (peds ≥2) |
History of anaphylaxis to IgG IgA-deficient with IgA antibodies |
IgA: <32 mcg/mL Osmolarity: 240 to 370 mOsm/L Stabilizer: sorbitol |
|
Gammagard 10% (liquid) |
PID (peds ≥2) MMN (adults) CIDP (adults) |
History of anaphylaxis to IgG IgA-deficient with IgA antibodies |
IgA: 37 mcg/mL Osmolality: 240 to 300 mOsm/kg Stabilizer: glycine |
May be used SC (see SCIG policy for criteria) |
Gammagard S/D 5%(lyophilized) |
PID (peds ≥2) cITP (adult) CLL Kawasaki (peds) |
History of anaphylaxis to IgG IgA-deficient with IgA antibodies |
IgA: ≤2.2 mcg/mL Osmolality: 636 mOsm/L Stabilizer: glycine |
Contains some sugar (20mg/mL when prepared) |
Gammaked 10% (liquid) |
PID (peds ≥2) aITP or cITP (peds/adults) CIDP (adults) |
History of anaphylaxis to IgG IgA-deficient with IgA antibodies |
IgA: 46 mcg/mL Osmolality: 258 mOsm/kg Stabilizer: glycine |
May be used SC (see SCIG policy for criteria) |
Gammaplex 5% (liquid) |
PID (peds ≥2) cITP (peds/adults) |
History of anaphylaxis to IgG IgA-deficient with IgA antibodies Fructose intolerance |
IgA: <10 mcg/mL Osmolality: 460 to 500 mOsm/kg Stabilizer: glycine |
Other stabilizer used is Polysorbate 80 |
Gammaplex 10% (liquid) |
PID (peds >2) cITP (adults) |
History of anaphylaxis to IgG IgA-deficient with IgA antibodies |
IgA: <20 mcg/mL Osmolality: 280 mOsm/kg Stabilizer: glycine |
Other stabilizer used is Polysorbate 80 |
Gamunex-C 10% (liquid) |
PID (peds ≥2) aITP or cITP (peds/adults) CIDP (adults) |
History of anaphylaxis to IgG IgA-deficient with IgA antibodies |
IgA: 46 mcg/mL Osmolality: 258 mOsm/kg Stabilizer: glycine |
May be used SC (see SCIG policy for criteria) |
Octagam 5% (liquid) |
PID (peds ≥6) |
History of anaphylaxis to IgG IgA-deficient with IgA antibodies Corn allergy |
IgA: ≤100 mcg/mL Osmolality: 310 to 380 mOsm/kg Stabilizer: maltose |
|
Octagam 10% (liquid) |
cITP (adults) Dermatomyositis (adult) |
History of anaphylaxis to IgG IgA-deficient with IgA antibodies |
IgA: 106 mcg/mL Osmolality: 310 to 380 mOsm/kg Stabilizer: maltose |
|
Panzyga 10% (liquid) |
PID (peds ≥2) cITP (adults) CIDP (adults) |
History of anaphylaxis to IgG IgA-deficient with IgA antibodies |
IgA: ≤100 mcg/mL Osmolality: 240 to 310 mOsm/kg Stabilizer: glycine |
|
Privigen 10% (liquid) |
PID (peds >3) cITP (ped ≥15) CIDP (adults) |
History of anaphylaxis to IgG IgA-deficient with IgA antibodies Hyperprolinemia |
IgA: ≤25 mcg/mL Osmolality: 320 mOsm/kg Stabilizer: L-proline |
|
Yimmugo 10% (liquid) |
PID (peds ≥2) |
History of anaphylaxis to IgG IgA-deficient with IgA antibodies |
IgA: ≤300 mcg/mL Osmolality: 280 to 380 mOsm/kg Stabilizer: N/A |
Does not contain carbohydrate stabilizers (e.g., sucrose, maltose) or preservatives |
|
||||
Adapted from: - Professional Resource, Comparison of IVIG Products. Pharmacist’s Letter/Prescriber’s Letter. December 2016. - Product package inserts - Characteristics of Immunoglobulin Products Used to Treat Primary Immunodeficiencies (PI). Immune Deficiency Foundation. April 2020 |
- Renewal Criteria 1-16,57,71
Coverage can be renewed based upon the following criteria:
For Commercial Members Only |
Treatment with Asceniv is considered excluded from coverage, unless the patient is continuing therapy with Asceniv |
For PEEHIP Members Only |
|
Note: unless otherwise specified, renewal authorizations are provided for 1 year
- Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include: renal dysfunction and acute renal failure, thrombosis, hemolysis, severe hypersensitivity reactions, pulmonary adverse reactions/transfusion-related acute lung injury (TRALI), hyperproteinemia, increased serum viscosity, hyponatremia, aseptic meningitis syndrome, hypertension, volume overload, etc.; AND
- BUN and serum creatinine have been obtained within the last 6 months and the concentration and rate of infusion have been adjusted accordingly; AND
Primary Immunodeficiency (PID) 1-16,38,54,56,57,70
- Disease response as evidenced by one or more of the following:
- Decrease in the frequency of infection
- Decrease in the severity of infection
IgG Subclass Deficiency 70,98,100
- Disease response as evidenced by one or more of the following:
- Decrease in the frequency of infection
- Decrease in the severity of infection; AND
- Continued treatment is necessary to decrease the risk of infection
Immune Thrombocytopenia/Idiopathic Thrombocytopenia Purpura (ITP) 2,5-9,11-13,32,37,39,81
- Acute ITP:
- May not be renewed.
- Chronic ITP:
- Disease response as indicated by the achievement and maintenance of a platelet count of ≥ 30 X 109/L and at least doubling the baseline platelet count
Chronic Inflammatory Demyelinating Polyneuropathy 4,6,7,12,13,18-22,24-26,42,44,72,116
- Renewals will be authorized for patients that have demonstrated a clinical response to therapy based on an objective clinical measuring tool (e.g., INCAT, Medical Research Council (MRC) muscle strength, 6-MWT, Rankin, Modified Rankin, etc.)
Guillain-Barre Syndrome (Acute inflammatory polyneuropathy) 58
- May not be renewed.
Multifocal Motor Neuropathy 1-14,19,21,22,24,25
- Renewals will be authorized for patients that have demonstrated a clinical response to therapy based on an objective clinical measuring tool (e.g., INCAT, Medical Research Council (MRC) muscle strength, 6-MWT, Rankin, Modified Rankin, etc.)
HIV Infected Children: Bacterial Control or Prevention 27,28,37,89
- Disease response as evidenced by one or more of the following:
- Decrease in the frequency of infection
- Decrease in the severity of infection; AND
- Patient continues to be at an increased risk of infection necessitating continued therapy as evidenced by an IgG level < 400 mg/dL
Myasthenia Gravis 53,78,85
- May not be renewed.
Dermatomyositis/Polymyositis 19,21,22,24,65,66,70,82
- Patient had an improvement from baseline on physical exam and/or muscular strength and function
Note: Renewal authorizations are provided for 6 months
Complications of Transplanted Solid Organ (kidney, liver, lung, heart, pancreas) and Bone Marrow Transplant 59-62,70,102
- Disease response as evidenced by one or more of the following:
- Decrease in the frequency of infection
- Decrease in the severity of infection; AND
- Continued treatment is necessary to decrease the risk of infection
Stiff Person Syndrome 21,24,64
- Documented improvement from baseline on physical exam
Allogeneic Bone Marrow or Stem Cell Transplant 76,102
- Patient continues to be at an increased risk of infection necessitating continued therapy as evidenced by an IgG level < 400 mg/dL
Note: Renewal authorizations are provided for 3 months
Kawasaki’s Disease 5,83
- May not be renewed.
Fetal Alloimmune Thrombocytopenia (FAIT) 33,38,48,85,90
- Authorization is valid through the delivery date only and cannot be renewed
Neonatal Alloimmune Thrombocytopenia 35-37,84
- May not be renewed.
Autoimmune Mucocutaneous Blistering Diseases 34,40,41,67-69,91,110-112
- Documented improvement from baseline on physical exam
Note: Renewal authorizations are provided for 6 months
Acquired Immune Deficiency Secondary to Acute Lymphoblastic Leukemia (ALL), Chronic Lymphocytic Leukemia (CLL), Small Lymphocytic Lymphoma (SLL), or Multiple Myeloma (MM) 37,70,79,92
- Disease response as evidenced by one or more of the following:
- Decrease in the frequency of infection
- Decrease in the severity of infection; AND
- Continued treatment is necessary to decrease the risk of infection
Toxic Shock Syndrome 46,93,94
- May not be renewed.
Management of Immune Checkpoint Inhibitor Related Toxicity 73,80
- May not be renewed.
Management of CAR T-Cell-Related Toxicity 73,80,86,104,105
- Patient has received treatment with anti-CD19 CAR T-cell therapy (e.g., axicabtagene ciloleucel, brexucabtagene autoleucel, lisocabtagene maraleucel, tisagenlecleucel, etc.); AND
- Patient has serum IgG levels <600 mg/dl; OR
- Patient is has received treatment with BCMA-targeted CAR T-cell therapy (e.g., idecabtagene vicleucel, ciltacabtagene autoleucel, etc.); AND
- Patient has serum IgG levels <400 mg/dL
Supportive Care after Rethymic transplant ‡ 97
- Renewals for use as initial immunoglobulin replacement therapy will be authorized until all of the following criteria are met:
- Patient is no longer on immunosuppression (at least 10% of CD3+ T cells are naïve in phenotype); AND
- Patient is at least 9 months post-treatment; AND
- Patient’s phytohemagglutinin (PHA) response within normal limits; OR
- Renewals for use as re-initiation of treatment after stopping immunoglobulin replacement therapy for patients with an IgG trough level lower than normal range will be continued for 1 year before being retested using the above guidelines
Dosing Recommendations:
|
- Dosage/Administration 1-16,24,25,32,41,53,58,63,64,76,78-80,83,84,89-94,99,101,102,106,110,111,116
Dosing should be calculated using adjusted body weight if one or more of the following criteria are met:
- Patient’s body mass index (BMI) is 30 kg/m2 or more; OR
- Patient’s actual body weight is 20% higher than his or her ideal body weight (IBW)
Use the following dosing formulas to calculate the adjusted body weight (round dose to nearest 5 gram increment in adult patients):
Dosing formulas |
BMI = 703 x (weight in pounds/height in inches2) |
IBW (kg) for males = 50 + [2.3 (height in inches – 60)] |
IBW (kg) for females = 45.5 + [2.3 x (height in inches – 60)] |
Adjusted body weight = IBW + 0.4 (actual body weight – IBW) |
This information is not meant to replace clinical decision making when initiating or modifying medication therapy and should only be used as a guide. Patient-specific variables should be taken into account.
Indication |
Dose ¤ |
PID and Supportive Care after Rethymic transplant |
200 to 800 mg/kg every 21 to 28 days |
IgG Subclass Deficiency |
300 to 400 mg/kg every 14 days |
CIDP |
2 g/kg divided over 2-5 days initially, then 1 g/kg administered in 1-2 infusions every 21 days |
ITP |
2 g/kg divided over 5 days or 1 g/kg once daily for 2 consecutive days in a 28-day cycle |
Fetal Alloimmune thrombocytopenia (FAIT) |
1 g/kg/week until delivery |
Kawasaki’s Disease |
1 g/kg to 2 g/kg x 1 dose, may be repeated once if needed |
Multifocal Motor Neuropathy |
Up to 2 g/kg divided over 5 days in a 28-day cycle |
Acquired immune deficiency: CLL, SLL, MM, and ALL |
400 mg/kg every 3 to 4 weeks |
HIV Infected Children |
400 mg/kg every 2 to 4 weeks |
Guillain-Barré |
2 g/kg divided over 5 days x 1 course. May be repeated once within 6 weeks of onset if needed |
Myasthenia Gravis |
1-2 g/kg divided as either 0.5 g/kg daily x 2 days or 0.4 g/kg daily x 5 days x 1 course |
Auto-immune blistering diseases |
Up to 2 g/kg divided over 5 days in a 28-day cycle |
Dermatomyositis/Polymyositis |
2 g/kg divided over 2 to 5 days in a 28-day cycle |
Allogeneic Bone Marrow or Stem Cell Transplant |
500 mg/kg once weekly x 90 days, then 500 mg/kg every 3 to 4 weeks |
Complications of transplanted solid organ (kidney, liver, lung, heart, pancreas) and bone marrow transplant |
2 g/kg divided over 5 days in a 28-day cycle |
Stiff Person Syndrome |
2 g/kg divided over 5 days in a 28-day cycle |
Toxic Shock Syndrome |
2 g/kg divided over 5 days x 1 course |
Neonatal Alloimmune Thrombocytopenia (NAIT) |
1 g/kg x 1 dose, may be repeated once if needed |
Management of Immune Checkpoint Inhibitor Related Toxicity |
2 g/kg divided over 5 days x 1 course |
Management of CAR T-Cell-Related Toxicity |
400-500 mg/kg every 28 days |
¤ Dosing for IVIG is highly variable depending on numerous patient specific factors, indication(s), and the specific product selected. For specific dosing regimens refer to current prescribing literature. |
- Billing Code/Availability Information
HCPCS Code & NDC:
Drug |
Manufacturer |
HCPCS Code |
1 Billable Unit Equivalent |
IgG (grams) per SDV |
NDC |
Alyglo |
GC Biopharma |
J1599 |
N/A |
5, 10, 20 |
61476-0104-XX |
Bivigam* |
ADMA Biologics |
J1556 |
500 mg |
5 |
69800-6502-XX |
10 |
69800-6503-XX |
||||
Flebogamma 10% DIF* |
Instituto Grifols, S.A. |
J1572 |
500 mg |
5, 10, 20 |
61953-0005-XX |
Flebogamma 5% DIF* |
0.5, 2.5, 5, 10, 20 |
61953-0004-XX |
|||
Gamunex-C |
Grifols Therapeutics |
J1561 |
500 mg |
1, 2.5, 5, 10, 20, 40 |
13533-0800-XX |
Gammagard Liquid* |
Baxalta |
J1569 |
500 mg |
1, 2.5, 5, 10, 20, 30 |
00944-2700-XX |
Gammagard S/D* |
Baxalta |
J1566 |
500 mg |
5 |
00944-2656-XX |
10 |
00944-2658-XX |
||||
Gammaked* |
Grifols Therapeutics |
J1561 |
500 mg |
1, 2.5, 5, 10, 20 |
76125-0900-XX |
Gammaplex 5%* |
Bio Products Laboratory |
J1557 |
500 mg |
5, 10, 20 |
64208-8234-XX |
Gammaplex 10%* |
5, 10, 20 |
64208-8235-XX |
|||
Octagam 10%* |
Octapharma USA Inc |
J1568 |
500 mg |
2, 5, 10, 20, 30 |
68982-0850-XX |
Octagam 5%* |
1, 2.5, 5, 10, 25 |
68982-0840-XX |
|||
Privigen* |
CSL Behring AG |
J1459 |
500 mg |
5 |
44206-0436-XX |
10 |
44206-0437-XX |
||||
20 |
44206-0438-XX |
||||
40 |
44206-0439-XX |
||||
Panzyga* |
Octapharma USA Inc |
J1576 |
500mg |
1, 2.5, 5, 10, 20, 30 |
68982-0820-XX |
Yimmugo |
Biotest AG |
J1599 |
N/A |
5, 10, 20 |
83372-0605-XX |
Injection, immune globulin, intravenous, non-lyophilized (e.g., liquid), not otherwise specified |
N/A |
J1599 |
500 mg |
N/A |
N/A |
*90283 – immune globulin (IgIV), human, for intravenous use |
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- Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) Multiple Myeloma, Version 1.2024. National Comprehensive Cancer Network, 2023. The NCCN Compendium® is a derivative work of the NCCN Guidelines®. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Compendium, go online to NCCN.org. Accessed October 2023.
- Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma, Version 3.2023. National Comprehensive Cancer Network, 2023. The NCCN Compendium® is a derivative work of the NCCN Guidelines®. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Compendium, go online to NCCN.org. Accessed October 2023.
- de Graeff N, Groot N, Ozen S, et al. European consensus-based recommendations for the diagnosis and treatment of Kawasaki disease - the SHARE initiative. Rheumatology (Oxford). 2019 Apr 1;58(4):672-682. doi: 10.1093/rheumatology/key344.
- Gorelik M, Chung SA, Ardalan K, et al. 2021 American College of Rheumatology/Vasculitis Foundation Guideline for the Management of Kawasaki Disease. Arthritis Care Res (Hoboken). 2022 Apr;74(4):538-548. doi: 10.1002/acr.24838.
- Schmidt E, Rashid H, Marzano A, et al. European Guidelines (s3) on diagnosis and management of mucous membrane pemphigoid, initiated by the european academy of dermatology and venereology - part ii. J Eur Acad Dermatol Venereology (2021) 35:1926–48. doi: 10.1111/jdv.17395
- Joly P, Horvath B, Patsatsi A, et al. Updated s2k guidelines on the management of pemphigus vulgaris and foliaceus initiated by the european academy of dermatology and venereology (eadv). J Eur Acad Dermatol Venereology (2020) 34:1900–13. doi: 10.1111/jdv.16752
- Borradori L, Beek NV, Feliciani C, et al. Updated s2 k guidelines for the management of bullous pemphigoid initiated by the european academy of dermatology and venereology (eadv). J Eur Acad Dermatol Venereology (2022) 36:1689–704. doi: 10.1111/jdv.18220
- Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) Hematopoietic Cell Transplantation, Version 3.2023. National Comprehensive Cancer Network, 2023. The NCCN Compendium® is a derivative work of the NCCN Guidelines®. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, and NCCN GUIDELINES® are trademarks owned by the National Comprehensive Cancer Network, Inc. To view the most recent and complete version of the Compendium, go online to NCCN.org. Accessed October 2023.
- Dalakas, M.C. Stiff-person Syndrome and GAD Antibody-spectrum Disorders: GABAergic Neuronal Excitability, Immunopathogenesis and Update on Antibody Therapies. Neurotherapeutics 19, 832–847 (2022).
- Hughes, RAC, Wijdicks EFM, Barohn R, et al. Practice parameter: Immunotherapy for Guillain–Barré syndrome Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology Sep 2003, 61 (6) 736-740; DOI: 10.1212/WNL.61.6.736
- Van den Bergh PYK, van Doorn PA, Hadden RDM, et al. European Academy of Neurology/Peripheral Nerve Society guideline on diagnosis and treatment of chronic inflammatory demyelinating polyradiculoneuropathy: Report of a joint Task Force-Second revision. J Peripher Nerv Syst. 2021 Sep;26(3):242-268. doi: 10.1111/jns.12455. Erratum in: J Peripher Nerv Syst. 2022 Mar;27(1):94. Erratum in: Eur J Neurol. 2022 Apr;29(4):1288.
- National Coverage Determination (NCD) for Intravenous Immune Globulin for the Treatment of Autoimmune Mucocutaneous Blistering Diseases (250.3). Centers for Medicare and Medicaid Services, Inc. Updated on 10/01/2002 with effective date 10/01/2002. Accessed January 2024.
- National Government Services, Inc. Local Coverage Article: Billing and Coding: Off-Label Use of Intravenous Immune Globulin (IVIG) (A59105). Centers for Medicare & Medicaid Services, Inc. Updated on 06/21/2023 with effective date 07/01/2023. Accessed January 2024.
- Noridian Healthcare Solutions, LLC. Local Coverage Article: Billing and Coding: Intravenous Immune Globulin (IVIg)-NCD 250.3 (A54641, A54643). Centers for Medicare & Medicaid Services, Inc. Updated on 11/17/2023 with effective date 11/07/2015. Accessed January 2024.
- Noridian Healthcare Solutions, LLC. Local Coverage Article: Billing and Coding: Coverage of Intravenous Immune Globulin for Treatment of Primary Immune Deficiency Diseases in the Home – Medicare Benefit Policy Manual, Chapter 15, 50.6 (A54660, A54662). Centers for Medicare & Medicaid Services, Inc. Updated 11/17/2023 with effective date 08/13/2019. Accessed January 2024.
- Noridian Healthcare Solutions, LLC. Local Coverage Article: Billing and Coding: Immune Globulin Intravenous (IVIg) (A57187). Centers for Medicare & Medicaid Services, Inc. Updated 11/16/2023 with effective date 07/01/2023. Accessed January 2024.
- Noridian Healthcare Solutions, LLC. Local Coverage Article: Billing and Coding: Immune Globulin Intravenous (IVIg) (A57194). Centers for Medicare & Medicaid Services, Inc. Updated 11/16/2023 with effective date 07/01/2023. Accessed January 2024.
- Wisconsin Physicians Service Insurance Corporation. Local Coverage Article: Billing and Coding: Immune Globulins (A57554). Centers for Medicare & Medicaid Services, Inc. Updated on 11/22/2022 with effective date 12/01/2022. Accessed January 2024.
- CGS, Administrators, LLC. Local Coverage Article: Billing and Coding: Immune Thrombocytopenia (ITP) Therapy (A57160). Centers for Medicare & Medicaid Services, Inc. Updated on 11/07/2023 with effective date 11/16/2023. Accessed January 2024.
- First Coast Service Options, Inc. Local Coverage Article: Billing and Coding: Immune Globulin (A57778). Centers for Medicare & Medicaid Services, Inc. Updated on 07/14/2023 with effective date 07/01/2023. Accessed January 2024.
- Novitas Solutions, Inc. Local Coverage Article: Billing and Coding: Immune Globulin (A56786). Centers for Medicare & Medicaid Services, Inc. Updated on 07/14/2023 with effective date 07/01/2023. Accessed January 2024.
- Palmetto GBA, LLC. Local Coverage Article: Intravenous Immunoglobulin (IVIG) (A56718). Centers for Medicare & Medicaid Services, Inc. Updated on 10/26/2023 with effective date 10/01/2023. Accessed January 2024.
- CGS, Administrators, LLC. Local Coverage Article: Billing and Coding: Intravenous Immune Globulin (A56779). Centers for Medicare & Medicaid Services, Inc. Updated on 11/07/2023 with effective date 11/16/2023. Accessed January 2024.
Appendix 1 – Covered Diagnosis Codes
ICD-10 |
ICD-10 Description |
A48.3 |
Toxic shock syndrome |
B20 |
Human immunodeficiency virus (HIV) disease |
B25.0 |
Cytomegaloviral pneumonitis |
B25.1 |
Cytomegaloviral hepatitis |
B25.2 |
Cytomegaloviral pancreatitis |
B25.8 |
Other cytomegaloviral diseases |
B25.9 |
Cytomegaloviral disease, unspecified |
C83.00 |
Small cell B-cell lymphoma, unspecified site |
C83.01 |
Small cell B-cell lymphoma, lymph nodes of head, face, and neck |
C83.02 |
Small cell B-cell lymphoma, intrathoracic lymph nodes |
C83.03 |
Small cell B-cell lymphoma, intra-abdominal lymph nodes |
C83.04 |
Small cell B-cell lymphoma, lymph nodes of axilla and upper limb |
C83.05 |
Small cell B-cell lymphoma, lymph nodes of inguinal region and lower limb |
C83.06 |
Small cell B-cell lymphoma, intrapelvic lymph nodes |
C83.07 |
Small cell B-cell lymphoma, spleen |
C83.08 |
Small cell B-cell lymphoma, lymph nodes of multiple sites |
C83.09 |
Small cell B-cell lymphoma, extranodal and solid organ sites |
C91.10 |
Chronic lymphocytic leukemia of B-cell type not having achieved remission |
C91.11 |
Chronic lymphocytic leukemia of B-cell type in remission |
C91.12 |
Chronic lymphocytic leukemia of B-cell type in relapse |
C90.00 |
Multiple Myeloma not having achieved remission |
C90.01 |
Multiple Myeloma in remission |
C90.02 |
Multiple Myeloma in relapse |
C90.10 |
Plasma cell leukemia not having achieved remission |
C90.11 |
Plasma cell leukemia in remission |
C90.12 |
Plasma cell leukemia in relapse |
C90.00 |
Acute lymphoblastic leukemia not having achieved remission |
C90.01 |
Acute lymphoblastic leukemia, in remission |
C90.02 |
Acute lymphoblastic leukemia, in relapse |
D69.3 |
Immune thrombocytopenic purpura |
D69.41 |
Evans syndrome |
D69.42 |
Congenital and hereditary thrombocytopenic purpura |
D69.49 |
Other primary thrombocytopenia |
D69.59 |
Other secondary thrombocytopenia |
D80.0 |
Hereditary hypogammaglobulinemia |
D80.1 |
Nonfamilial hypogammaglobulinemia |
D80.3 |
Selective deficiency of immunoglobulin G [IgG] subclasses |
D80.5 |
Immunodeficiency with increased immunoglobulin M [IgM] |
D80.7 |
Transient hypogammaglobulinemia of infancy |
D81.0 |
Severe combined immunodeficiency [SCID] with reticular dysgenesis |
D81.1 |
Severe combined immunodeficiency [SCID] with low T- and B-cell numbers |
D81.2 |
Severe combined immunodeficiency [SCID] with low or normal B-cell numbers |
D81.6 |
Major histocompatibility complex class I deficiency |
D81.7 |
Major histocompatibility complex class II deficiency |
D81.89 |
Other combined immunodeficiencies |
D81.9 |
Combined immunodeficiency, unspecified |
D82.0 |
Wiskott-Aldrich syndrome |
D82.1 |
DiGeorge's syndrome |
D82.8 |
Immunodeficiency associated with other specified major defects |
D83.0 |
Common variable immunodeficiency with predominant abnormalities of B-cell numbers and function |
D83.2 |
Common variable immunodeficiency with autoantibodies to B- or T-cells |
D83.8 |
Other common variable immunodeficiencies |
D83.9 |
Common variable immunodeficiency, unspecified |
D89.810 |
Acute graft-versus-host disease |
D89.812 |
Acute on chronic graft-versus-host disease |
D89.834 |
Cytokine release syndrome, grade 4 |
D89.839 |
Cytokine release syndrome, grade unspecified |
G03.8 |
Meningitis due to other specified causes |
G03.9 |
Meningitis, unspecified |
G04.81 |
Other encephalitis and encephalomyelitis |
G04.89 |
Other myelitis |
G04.90 |
Encephalitis and encephalomyelitis, unspecified |
G04.91 |
Myelitis, unspecified |
G25.82 |
Stiff-man syndrome |
G56.80 |
Other specified mononeuropathies of unspecified upper limb |
G56.81 |
Other specified mononeuropathies of right upper limb |
G56.82 |
Other specified mononeuropathies of left upper limb |
G56.83 |
Other specified mononeuropathies of bilateral upper limbs |
G56.90 |
Unspecified mononeuropathy of unspecified upper limb |
G56.91 |
Unspecified mononeuropathy of right upper limb |
G56.92 |
Unspecified mononeuropathy of left upper limb |
G56.93 |
Unspecified mononeuropathy of bilateral upper limbs |
G57.80 |
Other specified mononeuropathies of unspecified lower limb |
G57.81 |
Other specified mononeuropathies of right lower limb |
G57.82 |
Other specified mononeuropathies of left lower limb |
G57.83 |
Other specified mononeuropathies of bilateral lower limbs |
G57.90 |
Unspecified mononeuropathy of unspecified lower limb |
G57.91 |
Unspecified mononeuropathy of right lower limb |
G57.92 |
Unspecified mononeuropathy of left lower limb |
G57.93 |
Unspecified mononeuropathy of bilateral lower limbs |
G61.0 |
Guillain-Barre syndrome |
G61.1 |
Serum neuropathy |
G61.81* |
Chronic inflammatory demyelinating polyneuritis |
G61.82 |
Multifocal motor neuropathy |
G61.89 |
Other inflammatory polyneuropathies |
G61.9 |
Inflammatory polyneuropathy, unspecified |
G62.0 |
Drug-induced polyneuropathy |
G62.89 |
Other specified polyneuropathies |
G70.00 |
Myasthenia gravis without (acute) exacerbation |
G70.01 |
Myasthenia gravis with (acute) exacerbation |
H46.9 |
Unspecified optic neuritis |
I30.8 |
Other forms of acute pericarditis |
I30.9 |
Acute pericarditis, unspecified |
I40.8 |
Other acute myocarditis |
I40.9 |
Acute myocarditis, unspecified |
J70.2 |
Acute drug-induced interstitial lung disorders |
J70.4 |
Drug-induced interstitial lung disorders, unspecified |
L10.0 |
Pemphigus vulgaris |
L10.2 |
Pemphigus foliaceous |
L12.0 |
Bullous pemphigoid |
L12.1 |
Cicatricial pemphigoid |
L12.30 |
Acquired epidermolysis bullosa, unspecified |
L12.31 |
Epidermolysis bullosa due to drug |
L12.35 |
Other acquired epidermolysis bullosa |
L12.5 |
Other acquired epidermolysis bullosa |
L13.8 |
Other specified bullous disorders |
L13.9 |
Bullous disorder, unspecified |
L51.1 |
Stevens-Johnson syndrome |
L51.2 |
Toxic epidermal necrolysis [Lyell] |
M30.3 |
Mucocutaneous lymph node syndrome [Kawasaki] |
M33.00 |
Juvenile dermatomyositis, organ involvement unspecified |
M33.01 |
Juvenile dermatomyositis with respiratory involvement |
M33.02 |
Juvenile dermatomyositis with myopathy |
M33.03 |
Juvenile dermatomyositis without myopathy |
M33.09 |
Juvenile dermatomyositis with other organ involvement |
M33.10 |
Other dermatomyositis, organ involvement unspecified |
M33.11 |
Other dermatomyositis with respiratory involvement |
M33.12 |
Other dermatomyositis with myopathy |
M33.13 |
Other dermatomyositis without myopathy |
M33.19 |
Other dermatomyositis 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 |
M33.93 |
Dermatopolymyositis, unspecified without myopathy |
M33.99 |
Dermatopolymyositis, unspecified with other organ involvement |
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 |
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 |
M79.10 |
Myalgia, unspecified site |
M79.11 |
Myalgia of mastication muscle |
M79.12 |
Myalgia of auxiliary muscles, head and neck |
M79.18 |
Myalgia, other site |
O26.40 |
Herpes gestationis, unspecified trimester |
O26.41 |
Herpes gestationis, first trimester |
O26.42 |
Herpes gestationis, second trimester |
O26.43 |
Herpes gestationis, third trimester |
O36.8210 |
Fetal anemia and thrombocytopenia, first trimester, not applicable or unspecified |
O36.8211 |
Fetal anemia and thrombocytopenia, first trimester, fetus 1 |
O36.8212 |
Fetal anemia and thrombocytopenia, first trimester, fetus 2 |
O36.8213 |
Fetal anemia and thrombocytopenia, first trimester, fetus 3 |
O36.8214 |
Fetal anemia and thrombocytopenia, first trimester, fetus 4 |
O36.8215 |
Fetal anemia and thrombocytopenia, first trimester, fetus 5 |
O36.8219 |
Fetal anemia and thrombocytopenia, first trimester, other fetus |
O36.8220 |
Fetal anemia and thrombocytopenia, second trimester, not applicable or unspecified |
O36.8221 |
Fetal anemia and thrombocytopenia, second trimester, fetus 1 |
O36.8222 |
Fetal anemia and thrombocytopenia, second trimester, fetus 2 |
O36.8223 |
Fetal anemia and thrombocytopenia, second trimester, fetus 3 |
O36.8224 |
Fetal anemia and thrombocytopenia, second trimester, fetus 4 |
O36.8225 |
Fetal anemia and thrombocytopenia, second trimester, fetus 5 |
O36.8229 |
Fetal anemia and thrombocytopenia, second trimester, other fetus |
O36.8230 |
Fetal anemia and thrombocytopenia, third trimester, not applicable or unspecified |
O36.8231 |
Fetal anemia and thrombocytopenia, third trimester, fetus 1 |
O36.8232 |
Fetal anemia and thrombocytopenia, third trimester, fetus 2 |
O36.8233 |
Fetal anemia and thrombocytopenia, third trimester, fetus 3 |
O36.8234 |
Fetal anemia and thrombocytopenia, third trimester, fetus 4 |
O36.8235 |
Fetal anemia and thrombocytopenia, third trimester, fetus 5 |
O36.8239 |
Fetal anemia and thrombocytopenia, third trimester, other fetus |
O36.8290 |
Fetal anemia and thrombocytopenia, unspecified trimester, not applicable or unspecified |
O36.8291 |
Fetal anemia and thrombocytopenia, unspecified trimester, fetus 1 |
O36.8292 |
Fetal anemia and thrombocytopenia, unspecified trimester, fetus 2 |
O36.8293 |
Fetal anemia and thrombocytopenia, unspecified trimester, fetus 3 |
O36.8294 |
Fetal anemia and thrombocytopenia, unspecified trimester, fetus 4 |
O36.8295 |
Fetal anemia and thrombocytopenia, unspecified trimester, fetus 5 |
O36.8299 |
Fetal anemia and thrombocytopenia, unspecified trimester, other fetus |
P61.0 |
Transient neonatal thrombocytopenia |
T80.82XA |
Complication of immune effector cellular therapy, initial encounter |
T80.82XS |
Complication of immune effector cellular therapy, sequela |
T80.89XA |
Other complications following infusion, transfusion and therapeutic injection, initial encounter |
T80.89XS |
Other complications following infusion, transfusion and therapeutic injection, sequela |
T86.00 |
Unspecified complication of bone marrow transplant |
T86.01 |
Bone marrow transplant rejection |
T86.02 |
Bone marrow transplant failure |
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 |
T86.12 |
Kidney transplant failure |
T86.13 |
Kidney transplant infection |
T86.19 |
Other complication of kidney transplant |
T86.20 |
Unspecified complication of heart transplant |
T86.21 |
Heart transplant rejection |
T86.22 |
Heart transplant failure |
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 |
T86.32 |
Heart-lung transplant failure |
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 |
T86.42 |
Liver transplant failure |
T86.43 |
Liver transplant infection |
T86.49 |
Other complications of liver transplant |
T86.810 |
Lung transplant rejection |
T86.811 |
Lung transplant failure |
T86.812 |
Lung transplant infection |
T86.818 |
Other complications of lung transplant |
T86.819 |
Unspecified complication of lung transplant |
T86.890 |
Other transplanted tissue rejection |
T86.891 |
Other transplanted tissue failure |
T86.892 |
Other transplanted tissue infection |
T86.898 |
Other complications of other transplanted tissue |
T86.899 |
Unspecified complication of other transplanted tissue |
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 |
Z48.290 |
Encounter for aftercare following bone marrow 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 |
Z94.81 |
Bone marrow transplant status |
Z94.83 |
Pancreas transplant status |
Z94.84 |
Stem cells transplant status |
*G61.81 is not payable when associated with diabetes mellitus, dysproteinemias, renal failure, or malnutrition
Appendix 2 – Centers for Medicare and Medicaid Services (CMS)
The preceding information is intended for non-Medicare coverage determinations. Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals. In addition, National Coverage Determinations (NCDs) and/or Local Coverage Determinations (LCDs) may exist and compliance with these policies is required where applicable. Local Coverage Articles (LCAs) may also exist for claims payment purposes or to clarify benefit eligibility under Part B for drugs which may be self-administered. The following link may be used to search for NCD, LCD, or LCA documents: https://www.cms.gov/medicare-coverage-database/search.aspx. Additional indications, including any preceding information, may be applied at the discretion of the health plan.
Medicare Part B Covered Diagnosis Codes |
||
Jurisdiction |
NCD/LCA/LCD Document (s) |
Contractor |
E |
A57187, A54660, A54641 |
Noridian Healthcare Solutions, LLC |
F |
A54643, A57194, A54662 |
Noridian Healthcare Solutions, LLC |
H, L |
A56786 |
Novitas Solutions, Inc. |
J, M |
A56718 |
Palmetto GBA |
N |
A57778 |
First Coast Service Options, Inc. |
5, 8 |
A57554 |
Wisconsin Physicians Service Insurance Corporation (WPS) |
6, K |
A59105 |
National Government Services, Inc. (NGS) |
15 |
A56779, A57160 |
CGS Administrators, LLC |
ALL |
250.3 |
ALL |
Medicare Part B Administrative Contractor (MAC) Jurisdictions |
||
Jurisdiction |
Applicable State/US Territory |
Contractor |
E (1) |
CA, HI, NV, AS, GU, CNMI |
Noridian Healthcare Solutions, LLC |
F (2 & 3) |
AK, WA, OR, ID, ND, SD, MT, WY, UT, AZ |
Noridian Healthcare Solutions, LLC |
5 |
KS, NE, IA, MO |
Wisconsin Physicians Service Insurance Corporation (WPS) |
6 |
MN, WI, IL |
National Government Services, Inc. (NGS) |
H (4 & 7) |
LA, AR, MS, TX, OK, CO, NM |
Novitas Solutions, Inc. |
8 |
MI, IN |
Wisconsin Physicians Service Insurance Corporation (WPS) |
N (9) |
FL, PR, VI |
First Coast Service Options, Inc. |
J (10) |
TN, GA, AL |
Palmetto GBA |
M (11) |
NC, SC, WV, VA (excluding below) |
Palmetto GBA |
L (12) |
DE, MD, PA, NJ, DC (includes Arlington & Fairfax counties and the city of Alexandria in VA) |
Novitas Solutions, Inc. |
K (13 & 14) |
NY, CT, MA, RI, VT, ME, NH |
National Government Services, Inc. (NGS) |
15 |
KY, OH |
CGS Administrators, LLC |