IVIG - BMC HealthNet Plan

and to prevent or control recurrent and chronic bacterial infections and to control
symptoms. 26,158
Also see Hyperimmunoglobulinemia E syndrome (Job’s syndrome).
2. Idiopathic thrombocytopenic purpura (ITP) or immune thrombocytopenia (IT)
acute and chronic (treatment). 1,3,5-6,9
A. Children (age ≤ 10 years) with ITP. Approve for one of the following (a, b, c,
or d) when IVIG is prescribed by or in consultation with a hematologist. In
children ≤ 10 years of age, use of IVIG is based on risk of bleeding and not on
platelet counts.
a. If there is significant acute (newly diagnosed or requiring therapy for
the first time) mucous membrane or other noncutaneous bleeding then
approve for 1 month. 15 In clinical trials IVIG shortened the duration of
severe thrombocytopenia.
b. If IVIG is required to prevent bleeding in a child with persistent (3 to
12 months) or chronic (≥ 12 months) ITP/IT, approve for 12 months.
c. If inaccessibility or noncompliance is a concern and the child is at risk
of bleeding, approve for 12 months. 13
d. If splenectomy, other surgery, dental extractions, or other procedures
likely to cause blood loss are needed, then approve for one month. 15
Most children do not require therapy with IVIG. 29 In emergency situations,
platelet transfusions given with IV corticosteroids and IVIG should be given for
intracranial hemorrhaging or other life-threatening or serious bleeding. 29
B. Adults and children (> 10 years) with ITP. Approve for one of the following
(a, b or c) when IVIG is prescribed by or in consultation with a hematologist.
a. If there is acute bleeding (newly diagnosed or requiring therapy for the
first time) in a patient with platelet count < 30,000 mm 3 who has tried
a corticosteroid (e.g., prednisone). Approve IVIG for 1 month. An
exception can be made for trying a corticosteroid, if a corticosteroid
has been tried in the past for ITP/IT, there is a contraindication to
corticosteroid therapy, or corticosteroids should be avoided (such as in
patients with diabetes). IVIG may be added to corticosteroid therapy if
thrombocytopenia persists or worsens after about 3 days of
corticosteroid therapy. 30
According to ASH guidelines if platelet count is < 20,000 to 30,000
mm 3 initial therapy is corticosteroids. 13,29 ASH guidelines state that
splenectomy is effective in normalizing platelet counts in patients who
have been refractory to glucocorticoids for several weeks or years, but
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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