IVIG - BMC HealthNet Plan

do not require treatment with IVIG, high-dose corticosteroids or any other specific
therapy. 17 Splenectomy should be considered in children with symptomatic, severe
thrombocytopenia for at least one year. 13-14 In Rh-positive children who relapse after
initial therapy, Rh0 [D] immune globulin is preferred, if it is effective, over IVIG. Longterm
corticosteroids are usually unacceptable in children due to adverse effects and
responses are not durable. Only 5% of children with ITP still have thrombocytopenia that
requires therapy after one year.
B-cell chronic lymphocytic leukemia (CLL) for prevention of bacterial infections in
patients with hypogammaglobulinemia and/or recurrent bacterial infections. 5 In one
placebo-controlled study, IVIG significantly reduced bacterial infections and the median
time to first bacterial infection for the IVIG patients was greater than 365 days vs. 192
days with placebo. The number of viral and fungal infections was not different between
the two groups.
Kawasaki disease for the prevention of coronary artery aneurysm. 5 Efficacy of IVIG in
conjunction with aspirin given in the acute phase of Kawasaki disease in reducing the
prevalence of coronary artery abnormalities is well-established. 18
Chronic inflammatory demyelinating polyneuropathy (CIDP) to improve
neuromuscular disability and impairment and for maintenance therapy to prevent
relapse. 6,19 Efficacy of IVIG was established in a multi-center, double-blind trial using
immune globulin intravenous caprylate/chromatography purified (Gamunex). Patients
with CIDP were randomized to IVIG or placebo given as a loading dose at baseline over
2 to 4 consecutive days and then a maintenance dose every 3 weeks for up to 24 weeks.
Patients who did not improve and maintain this improvement for 24 weeks were crossed
over to the alternate study drug (rescue). Significantly more patients responded to IVIG
47.5% vs. 22.4% with placebo (25% difference; 95% confidence interval [CI] 7% - 43%;
P = 0.006). This study included patients who were IVIG naïve and subjects who had
previously received IVIG. See table 1. In an extension phase, time to relapse was
evaluated in the subset of patients who previously responded to IVIG, i.e., patients who
completed the efficacy phase or rescue phase for 24 weeks; 31 were randomly reassigned
to continue with IVIG and 26 were reassigned to placebo (withdrawal period) for 24
weeks. Subjects who continued on IVIG had a significantly longer time to relapse vs.
patient on placebo (P = 0.011). The probability of relapse was 13% with IVIG vs. 45%
with placebo (hazard ratio, 0.19 [95% CI, 0.05, 0.70]).
Table 1. Outcomes in Intent-to-Treat Population Efficacy Period (24 weeks). 6
IVIG
Placebo
Efficacy Period Responder* Non- Responder* Non- P-
Responder
Responder Value**
All subjects 28/59 (47.5%) 31/59 (52.5%) 13/58 (22.4%) 45/58 (77.6%) 0.006
IVIG naïve 17/39 (43/6%) 22/39 (56.4%) 13/46 (28.3%) 33/46 (71.7%) 0.174
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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