About this policy
Jurisdiction: JM Part B. States: North Carolina, South Carolina, Virginia, West Virginia. Type: Active LCD
Coverage indications
Intravenous Immune Globulin (IVIG) is a solution of human immunoglobulins specifically prepared for intravenous infusion. Immunoglobulins contain a broad range of antibodies that act specifically against bacterial and viral antigens. INDICATIONS: Treatment of primary immunodeficiency syndromes associated with defects in humoral immunity to replace or boost immunoglobulin G (IgG) Treatment of idiopathic thrombocytopenic purpura (ITP) when a rapid rise in the platelet count is required such as prior to surgery, to control excessive bleeding, or to defer or avoid splenectomy Treatment of Kawasaki disease, in conjunction with aspirin Prevention of recurrent bacterial infections in patients with hypogammaglobulinemia associated with B-cell chronic lymphocytic leukemia (CLL) Decreasing risk of acute graft versus host disease, associated interstitial pneumonia, and infections after bone marrow transplant in the first 100 days after transplantation Reducing the risk of severe bacterial infections in human immunodeficiency virus (HIV) infected children with a CD4 count of greater than 200 to 400 Second-line treatment of certain autoimmune myopathies Treatment of adults with Guillain-Barr é syndrome diagnosed within the first 2 weeks of illness Treatment of hyperimmunoglobulinemia E syndrome and Lambert-Eaton myasthenic syndrome (LEMS) Treatment of multifocal motor neuropathy (MMN) Treatment of relapsing-remitting multiple sclerosis Treatment of chronic parvovirus B19 infection and severe anemia associated with bone marrow suppression and pure red cell aplasia Treatment of progressive pemphigus vulgaris, pemphigus foliaceus, bullous pemphigoid, mucous membrane pemphigoid, and epidermolysis bullosa acquisita in patients that have failed conventional treatment and patients in whom conventional therapy is otherwise contraindicated For coverage criteria of autoimmune mucocutaneous blistering diseases, please see CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §250.3 Treatment of stiff person syndrome Treatment of myasthenia gravis (MG) in patients who have profound, rapidly progressive and/or potentially life-threatening muscular weakness and are refractory to, or intolerant of cholinesterase inhibitors, corticosteroids and azathioprine Prevention and/or treatment of organ rejection in patients sensitized to living or cadaveric organ donors Schonlein-Henoch Treatment of paraneoplastic visual loss Treatment of chronic inflammatory demyelinating polyneuropathy (CIDP) in patients meeting the necessary criteria Treatment of multiple myeloma for the prevention of life-threatening infections due to reduced gamma globulins
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.
| Code | Code system | Status in this policy |
|---|---|---|
| J1459 | HCPCS | Covered |
| J1552 | HCPCS | Covered |
| J1554 | HCPCS | Covered |
| J1556 | HCPCS | Covered |
| J1557 | HCPCS | Covered |
| J1561 | HCPCS | Covered |
| J1566 | HCPCS | Covered |
| J1568 | HCPCS | Covered |
| J1569 | HCPCS | Covered |
| J1576 | HCPCS | Covered |
| J1599 | HCPCS | Covered |
| J2791 | HCPCS | Covered |
| J2792 |