IVIG - BMC HealthNet Plan

GVHD, acute (within first 100 days after transplantation). Not recommended.
(See Exclusions.)
GVHD, chronic, prevention. Not recommended. (See Exclusions.)
HSCT in allogeneic recipients from HLA-identical sibling donors. Not
recommended. (See Exclusions.)
Autologous bone marrow transplantation or HSCT. Not recommended in
autologous transplants. 1 (See Exclusions.)
Although IVIG is used for immune system modulation, IVIG is not recommended
for cytomegalovirus (CMV) disease prophylaxis in HSCT recipients. 39 (See
Exclusions.)
7. Human immunodeficiency virus (HIV) infected infants and children younger
than 13 years of age. HIV infected infants and children is divided into A. Prevention
of recurrent bacterial infections and B. Passive immunization for Varicella.
A. For prevention of recurrent bacterial infections in HIV-infected infants
and children < 13 years of age. Approve for 12 months for patients who
meet all of the following criteria (a, b, and c).
a. IVIG is prescribed by an infectious disease specialist or an
immunologist, and
b. The patient is receiving highly active antiretroviral therapy (HAART)
(Note: HAART is a combination of three or more anti-HIV drugs
taken at the same time), and
c. The patient has one of the following (i, ii, or iii)
i. functional antibody deficiency as demonstrated by recurrent,
serious bacterial infections, defined as 2 or more serious bacterial
infections, such as bacteremia, meningitis, or pneumonia during a
1-year period despite administration of highly active antiretroviral
therapy (HAART) and prophylactic cotrimoxazole (TMP-SMZ) or
other antimicrobials 44-48 or
ii. functional antibody deficiency as demonstrated by the absence of
detectable antibody response against protein and polysaccharide
antigens, 47 or
iii. hypogammaglobulinemia (IgG < 400 mg/dL [4.0 g/L]). 47
IVIG is no longer recommended for primary prevention of serious bacterial
infections in HIV-infected children unless hypogammaglobulinemia is present or
functional antibody deficiency is demonstrated by either poor specific antibody
titers or recurrent bacterial infections. 47
This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this
guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is
based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence
to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider.
Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the
most recent CPT and HCPCS coding guidelines.
BMC HealthNet Plan – IVIG
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