IVIG - BMC HealthNet Plan

used in patients with severe active SLE for whom other interventions have been
unsuccessful or intolerable. 24 Well-controlled trials are needed to determine which
subsets of patients will benefit the most from IVIG. IVIG is used to treat severe
thrombocytopenia or immune neutropenia. 97 Its role in non-hematologic
manifestations of lupus is less clear. It has been used effectively to treat lupus
nephritis. 97-98 First line therapy for active SLE is corticosteroids and antimalarial
drugs (hydroxychloroquine). Second-line drugs are azathioprine, methotrexate,
cyclophosphamide, or rituximab.
44. Thrombocytopenia refractory to platelet transfusions. Approve for 12 months.
Evidence does not support routine use of IVIG but IVIG may have a role in patients
with severe thrombocytopenia of documented immune basis for whom other
modalities are unsuccessful or contraindicated. 23
45. Thrombocytopenia, fetal alloimmune. Approve maternal antenatal infusion of IVIG
for 6 months. 23,30,99 Antenatal therapy with IVIG is effective in increasing fetal
platelet counts in neonatal alloimmune thrombocytopenia. 99-100 IVIG reduces the risk
of intracranial hemorrhage and increases the fetal platelet count. In newborns with
fetal/neonatal alloimmune thrombocytopenia, first-line therapy is antigen-negative
compatible platelets and IVIG is adjunctive. 30
Transplantation. See End stage heart failure, renal disease, lung or liver disease. See
Small bowel transplant.
46. Urticaria, chronic autoimmune. Approve for 6 months of therapy in patients with
chronic autoimmune urticaria who have tried all of the following medications:
A. a first generation antihistamine (e.g., chlorpheniramine, diphenhydramine,
hydroxyzine),
B. a second generation antihistamine (e.g., loratadine, cetirizine (Zyrtec ® ),
fexofenadine, desloratadine (Clarinex ® )),
C. an H2-receptor antagonist (e.g., ranitidine, cimetidine, doxepine),
D. a corticosteroid, and
E. at least one of the following: cyclosporine, montelukast (Singulair ® ).
After initial 6 months approve for another 6 months if patient is improved. Further
authorization after 12 months total is not recommended.
One cycle (5 days) of IVIG was beneficial in 9 of 10 patients with chronic
autoimmune urticaria who had poor responses to antihistamines with 3 of the
patients having prolonged remission. 101 In a single center open-label study, 29
patients with autoimmune urticaria received 0.15 mg/kg of IVIG every 4 weeks
for a minimum of 6 months and a maximum of 51 months. 102 There was clinical
improvement in 26 patients with reduced urticaria or angioedema and decreased
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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