Immune Globulin Therapy
|
|
- Allison Todd
- 5 years ago
- Views:
Transcription
1 Immune Globulin Therapy Policy Number: Original Effective Date: MM /21/1999 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST 03/01/2015 Section: Prescription Drugs Place(s) of Service: Home; Outpatient; Ambulatory Infusion Suite I. Description Intravenous immune globulin (IVIG) is a sterile, highly purified preparation of unmodified immunoglobulins, which are isolated from large pools of human plasma. IVIG is an infusion used to treat patients with inherited or acquired immune deficiencies. It provides passive immunity against infection by increasing a person s antibody titer and antigen-antibody reaction potential. IVIG supplies a broad spectrum of IgG antibodies against bacterial, viral, parasitic, and mycoplasmal antigens. Subcutaneous immune globulin (Sub-q IG) is FDA approved for the treatment of patients with primary immune deficiency. It is injected under the skin using an infusion pump, which means patients can self-administer the product in a home setting. II. Criteria/Guidelines A. IVIG therapy is covered (subject to Limitations/Exclusions and Administrative Guidelines) for the following indications: 1. Treatment of primary immunodeficiencies, including, congenital agammaglobulinemia ( X- linked agammaglobulinemia),hypogammaglobulinemia,common variable immunodeficiency,x-linked immunodeficiency with hyperimmunoglobulin M,severe combined immunodeficiency and Wiskott-Aldrich syndrome for patients meeting all of the following criteria: a. Laboratory evidence of immunoglobulin deficiency (see Appendix) b. Documented Inability to mount an adequate response to inciting antigens (see Appendix) c. Persistent and severe infections despite treatment with prophylactic antibiotics 2. Idiopathic thrombocytopenic purpura (ITP)
2 Immune Globulin Therapy 2 3. Prevention of graft-versus-host disease in non-autologous bone marrow transplant patients age 20 or older in the first 100 days after transplantation 4. Kawasaki syndrome when used in conjunction with aspirin 5. Prevention of infection in: a. HIV-infected pediatric patients b. Bone marrow transplant patients age 20 or older in the first 100 days after transplantation c. Patients with primary defective antibody synthesis d. Patients with hypogammaglobulinemia and recurrent bacterial infections associated with B-cell chronic lymphocytic leukemia (CLL) 6. Refractory dermatomyositis when used as second line treatment for patients who are unresponsive to corticosteroid therapy 7. Fetal alloimmune thrombocytopenia 8. Myasthenic gravis when one of the following criteria are met: a. Patient has a myasthenic crisis, i.e., an acute episode of respiratory muscle weakness, and contraindications to plasma exchange b. Patient has chronic debilitating disease despite treatment with cholinesterase inhibitors, or who have complications from or failure of steroids and/or azathioprine 9. The following autoimmune mucocutaneous blistering diseases, in patients with severe progressive disease despite treatment with conventional agents (corticosteroids, azathioprine, cyclophosphamide, etc.). a. Pemphigus vulgaris b. Pemphigus foliaceus c. Bullous pemphigoid d. Mucous membrane pemphigoid (cicatrical pemphigoid, benign mucous membrane pemphigoid), with or without mention of ocular involvement e. Epidermolysis bullosa acquisita B. IVIG therapy is covered (subject to Limitations/Exclusions and Administrative Guidelines) for the following indications with precertification: 1. Chronic inflammatory demyelinating polyneuropathy (CIDP) in patients who meet all of the following criteria: a. Initial treatment: i. Significant functional disability ii. Slowing of nerve conduction velocity on EMG/NCS iii. Elevated spinal fluid protein on lumbar puncture or a nerve biopsy confirming the diagnosis b. Continuation of treatment: i. Patient demonstrates significant improvement in clinical condition and, when relevant, a reduction in the level of sensory loss
3 Immune Globulin Therapy 3 ii. For long-term treatment (e.g., over two years) of stable patients, the dose must be periodically reduced or withdrawn, and the effects measured, in order to validate continued use 2. Guillain-Barre syndrome as an alternative to plasma exchange for patients who meet one of the following criteria: a. Deteriorating pulmonary function tests b. Rapid deterioration with symptoms for less than two weeks c. Rapidly deteriorating ability to ambulate d. Frank inability to ambulate independently for ten meters 3. Multifocal motor neuropathy in patients with anti-gm1 antibodies and conduction block when conventional therapy is ineffective or not tolerated. C. Subcutaneous IG is covered (subject to Limitations/Exclusions and Administrative Guidelines) for the treatment of primary immunodeficiencies (see criteria under II. A.1) for patients who are not able to tolerate IVIG. III. Limitations/Exclusions Immune globulin therapy is not covered for the following indications including, but not limited to: A. Chronic progressive and relapsing/remitting multiple sclerosis B. Refractory rheumatoid arthritis and other connective tissue diseases C. Recurrent spontaneous abortion D. Inclusion-body myositis E. Polymyositis F. Myasthenia gravis in patients responsive to immunosuppressive treatment G. Vasculitides other than Kawasaki disease, including vasculitis associated with anti-neutrophol cytoplasmic antibodies (i.e., Wegener s granulomatosis, polyarteritis nodosa) Goodpasture s syndrome, and vasculitis associated with other connective tissue diseases. H. Chronic sinusitis I. Asthma J. Chronic fatigue syndrome K. Aplastic anemia L. Acute lymphoblastic leukemia M. Multiple myeloma N. Cystic fibrosis O. Recurrent otitis media P. Diabetes mellitus IV. Administrative Guidelines A. Precertification is required and may be approved for up to six months for the following indications: 1. Chronic inflammatory demyelinating polyneuropathy (CIDP): Requests must include all of the following documentation:
4 Immune Globulin Therapy 4 a. Clinical notes documenting functional disability b. EMG/NCS report c. Spinal fluid protein and/or nerve biopsy report 2. Guillain-Barre syndrome: Requests must include the following documentation: a. Pulmonary function test; or b. Clinical notes documenting the patient s functional status and course of illness 3. Multifocal motor neuropathy in patients with anti-gm1 antibodies and conduction block. Requests must include the conventional therapies that were tried and found to be ineffective, not tolerated or contraindicated B. If the patient requires therapy beyond the authorized duration, an extension request must be submitted with the physician's updated orders, clinical information substantiating that IVIG is effective, and the need for the extension. 1. For CIDP following the initial treatment regimen, documentation that demonstrates significant improvement in clinical condition and, when relevant, a reduction in the level of sensory loss must be submitted. 2. For the long-term treatment of stable CIDP patients, documentation that the dose has been periodically reduced or withdrawn, and the effects measured, in order to validate continued use must be submitted. C. Precertification is required for subcutaneous IG. Requests must include documentation supporting that the patient is not able to tolerate IVIG. D. To precertify please complete HMSA's Drug Review Request and mail or fax the form as indicated, along with the necessary documentation. E. A precertification request is usually submitted by the IV therapy provider. Physicians, however, should provide IV therapy providers with updated orders, clinical information and any other pertinent documentation that would be used to meet precertification requirements. F. For services that do not require precertification, HMSA reserves the right to perform retrospective review using the above criteria to validate if services rendered met payment determination criteria. G. For administrative information, including billing instructions, examples and code information, see Intravenous Immune Globulin (IVIG) Therapy - Administrative Information. H. Applicable codes: CPT code Description Immune globulin(igv), human, for intravenous use Immune globulin (SCIG),human, for use in subcutaneous infusions, 100mg, each HCPCS Code Description
5 Immune Globulin Therapy 5 J1459 J1557 J1559 J1561 J1566 J1568 J1569 J1572 J1599 Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g. liquid), 500 mg Injection, immune globulin, (Gammaplex), intravenous, nonlyophilized (e. g. liquid), 500 mg Injection, immune globulin (Hizentra), 100 mg Injection, immune globulin, (Gamunex,Gamunex-c Gammaked), non- lyophilized (e.g. liquid), 500 mg Injection, immune globulin, intravenous, lyophilized (e.g. powder), not otherwise specified, 500 mg Injection, immune globulin, (Octagam), intravenous, nonlyophilized, (e.g., liquid), 500mg Injection, immune globulin, (Gammagard), intravenous, nonlyophilized (e.g. liquid), 500 mg Injection, immune globulin, (Flebogamma/Flebogamma dif), intravenous, non- lyophilized (e.g. liquid), 500 mg Injection, immune globulin, intravenous, nonlyophilized (e.g., liquid), not otherwise specified, 500 mg ICD-9-CM Code Description Bacterial infection, code range 042 Human immunodeficiency virus (HIV) disease Chronic lymphoid leukemia Hypogammaglobulinemia, unspecified Immunodeficiency (X-linked) Common variable immunodeficiency Wiskott-Aldrich syndrome Combined immunity deficiency Unspecified immunity deficiency Acute graft versus host disease Primary thrombocytopenia, unspecified Immune thrombocytopenia purpura Thrombocytopenia, unspecified Mononeuritis, code range
6 Immune Globulin Therapy Idiopathic peripheral neuropathy, code range Myasthenia gravis Conduction disorders, code range Acute febrile mucocutaneous lymph node syndrome (Kawasaki disease) Pemphigus (includes pemphigus vulgaris or pemphigus foliaceus) Pemphigoid (includes bullous pemphigoid) Benign muccous membrane pemphigoid (a.k.a., cicatrical pemphigoid) without mention of ocular involvement with ocular involvement Other specified bullous dermatoses Dermatomyositis Transient neonatal thrombocytopenia Graft versus host disease V42.81 Bone marrow replaced by transplant ICD-10 codes are provided for your information. These will not become effective no sooner than 10/1/2015. ICD-10-CM Code Description A49.01 Methicillin susceptible Staphylococcus aureus infection, unspecified site A49.02 Methicillin resistant Staphylococcus aureus infection, unspecified site A49.1 Streptococcal infection, unspecified site A49.2 Hemophilus influenzae infection, unspecified site A49.3 Mycoplasma infection, unspecified site A49.8 Other bacterial infections of unspecified site A49.9 Bacterial infection, unspecified B20 Human immunodeficiency virus [HIV] disease B95.0 B95.8 Streptococcus, Staphylococcus as the cause of diseases classified elsewhere range B96.0 B96.89 Other bacterial agents as the cause of diseases classified elsewhere range
7 Immune Globulin Therapy 7 C91.10 C91.11 Chronic lymphocytic leukemia of B-cell type range D47.3 Essential (hemorrhagic) thrombocythemia D69.3 Immune thrombocytopenic purpura D69.6 Thrombocytopenia, unspecified D80.0 D80.9 Immunodeficiency with predominantly antibody defects range D81.0 D81.9 Combined immunodeficiencies D81.89 Other combined immunodeficiencies D82.0 Wiskott-Aldrich syndrome D83.0 D83.9 Common variable immunodeficiency range D84.9 Immunodeficiency, unspecified D Acute graft-versus-host disease E08.41 Diabetes mellitus due to underlying condition with diabetic mononeuropathy E09.41 Drug or chemical induced diabetes mellitus with neurological complications with diabetic mononeuropathy E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy E13.41 Other specified diabetes mellitus with diabetic mononeuropathy G56.00 G56.92 Mononeuropathies of upper limb range G57.00 G57.92 Mononeuropathies of lower limb range G60.3 Idiopathic progressive neuropathy G60.8 Other hereditary and idiopathic neuropathies G60.9 Hereditary and idiopathic neuropathy, unspecified G70.00 Myasthenia gravis without (acute) exacerbation G70.01 Myasthenia gravis with (acute) exacerbation I44.0 I44.7 Atrioventricular and left bundle-branch block range I45.0 I45.9 Other conduction disorders range J20.0 Acute bronchitis due to Mycoplasma pneumoniae J20.1 Acute bronchitis due to Hemophilus influenzae J20.2 Acute bronchitis due to streptococcus L10.0 L10.9 Pemphigus code range
8 Immune Globulin Therapy 8 L12.0 to L12.9 Pemphigoid code range L13.0 to L13.9 Other bullous disorders code range L14 Bullous disorders in diseases classified elsewhere M00.10 Pneumococcal arthritis, unspecified joint M Pneumococcal arthritis, right shoulder M Pneumococcal arthritis, left shoulder M Pneumococcal arthritis, unspecified shoulder M Pneumococcal arthritis, right elbow M Pneumococcal arthritis, left elbow M Pneumococcal arthritis, unspecified elbow M Pneumococcal arthritis, right wrist M Pneumococcal arthritis, left wrist M Pneumococcal arthritis, unspecified wrist M Pneumococcal arthritis, right hand M Pneumococcal arthritis, left hand M Pneumococcal arthritis, unspecified hand M Pneumococcal arthritis, right hip M Pneumococcal arthritis, left hip M Pneumococcal arthritis, unspecified hip M Pneumococcal arthritis, right knee M Pneumococcal arthritis, left knee M Pneumococcal arthritis, unspecified knee M Pneumococcal arthritis, right ankle and foot M Pneumococcal arthritis, left ankle and foot M Pneumococcal arthritis, unspecified ankle and foot M00.18 Pneumococcal arthritis, vertebrae M00.19 Pneumococcal polyarthritis M30.3 Mucocutaneous lymph node syndrome [Kawasaki] M33.00 to M33.99 Dermatopolymyositis code range M36.0 Dermato(poly)myositis in neoplastic disease P61.0 Transient neonatal thrombocytopenia
9 Immune Globulin Therapy 9 T86.00 T86.99 this is the underlying condition billed in the primary position when billed w/code: D D Complications of transplanted organs and tissues code range Graft-versus-host disease code range Z Encounter for aftercare following bone marrow transplant Z94.81 Bone marrow transplant status V. Important Reminder The purpose of this Medical Policy is to provide a guide to coverage. This Medical Policy is not intended to dictate to providers how to practice medicine. Nothing in this Medical Policy is intended to discourage or prohibit providing other medical advice or treatment deemed appropriate by the treating physician. Benefit determinations are subject to applicable member contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control. This Medical Policy has been developed through consideration of the medical necessity criteria under Hawaii s Patients Bill of Rights and Responsibilities Act (Hawaii Revised Statutes 432E-1.4), generally accepted standards of medical practice and review of medical literature and government approval status. HMSA has determined that services not covered under this Medical Policy will not be medically necessary under Hawaii law in most cases. If a treating physician disagrees with HMSA s determination as to medical necessity in a given case, the physician may request that HMSA consider the application of this Medical Policy to the case at issue. VI. References 1. BCBSA Medical Policy Reference Manual: Immune Globulin Therapy , Revised May Centers for Medicare and Medicaid Services. LCD for Intravenous Immune Globulin (IVIg) (L28275). Revision effective date 1/1/ Centers for Medicare and Medicaid Services. National Coverage Determination for Intravenous Immune Globulin for the Treatment of Autoimmune Mucocutaneous Blistering Diseases. NCD # Effective October 1, Chen C, Danekas LH, Ratko TA, et. al. A multicenter drug use surveillance of intravenous immunoglobulin utilization in U.S. academic health centers. Ann Pharmacother March; 34(3): Latov N., Gorson K., et al. Diagnosis and treatment of chronic immune-mediated neuropathies, Review article J Clin Neuromusc Dis; 2006; 7: Massachusetts General Hospital transfusion committee consensus, indications for IVIG, Oct
10 Immune Globulin Therapy Ratko TA, Brunett DA, Foulke GE, et al. Recommendations for Off-label Use of Intravenously Administered Immunoglobulin Preparations. University Hospital Consortium Expert Panel for Off-Label Use of Polyvalent Intravenously Administered Immunoglobulin Preparations. JAMA; 1995 June 21; 273(23): Micromedex; Drugdex Evaluations, Immune Globulin, Last modified August 27, FDA. Privigen prescribing information. CSL Behring AG Bern, Switzerland Rev. April Evidence-based guideline: Intravenous immunoglobulin in the treatment of neuromuscular disorders. Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2012;78: Position statement on the appropriate use of intravenously administered immunoglobulin (IGIV) from the American Academy of Allergy Asthma and Immunology VII. Appendix Primary Immunodeficiency Syndromes. The diagnosis of immunodeficiency and post immunization titers must be taken in context with the clinical presentation of the patient and may vary dependent on the type of vaccine given and the prior immunization history of the patient. The following parameters are examples of criteria for diagnosis of the primary immunodeficiency syndromes. Laboratory evidence of immunoglobulin deficiency may include the following definitions: Agammaglobulinemia (total IgG less than 200 mg/dl) Persistent hypogammaglobulinemia (total IgG less than 400 mg/dl, or at least two standard deviations below normal, on at least two occasions) Absence of B lymphocytes Inability to mount an adequate antibody response to inciting antigens may include the following definitions: Lack of appropriate rise in antibody titer following provocation with a polysaccharide antigen. For example, an adequate response to the pneumococcal vaccine may be defined as at least a 4-foldincrease in titers for at least 50% of serotypes tested. Lack of appropriate rise in antibody titer following provocation with a protein antigen. For example, an adequate response to tetanus/diphtheria vaccine may be defined as less than a 4-fold rise in titers 3-4 weeks after vaccine administration.
Immune Globulin Therapy
Immune Globulin Therapy Policy Number: Original Effective Date: MM.04.015 05/21/1999 Line(s) of Business: Current Effective Date: HMO; PPO 08/26/2011 Section: Prescription Drugs Place(s) of Service: Outpatient
More informationImmune Globulins. Subcutaneous Immune Globulin: Cuvitru, Hizentra and HyQvia
Immune Globulins Intravenous Immune Globulin (IVIG): Bivigam, Carimune NF, Flebogamma DIF, Gammagard Liquid, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Octagam, and Privigen Subcutaneous Immune Globulin:
More informationIntravenous Immune Globulins (IVIG)
Intravenous Immune Globulins (IVIG) Intravenous Immune Globulin (IVIG): Bivigam, Carimune NF, Flebogamma DIF, Gammagard Liquid, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Octagam, and Privigen Subcutaneous
More informationDrug Class Prior Authorization Criteria Immune Globulins
Drug Class Prior Authorization Criteria Immune Globulins Line of Business: Medicaid P & T Approval Date: August 16, 2017 Effective Date: August 16, 2017 This policy has been developed through review of
More informationIntravenous Immune Globulin (IVIg)
Policy Number Reimbursement Policy IVIG04272010RP Approved By UnitedHealthcare Medicare Reimbursement Policy Committee Current Approval Date 10/08/2014 IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY This
More informationIMMUNE GLOBULIN (IVIG AND SCIG) Brand Name Generic Name Length of Authorization Bivigam IVIG Per Medical Guidelines Carimune IVIG Per Medical
Brand Name Generic Name Length of Authorization Bivigam IVIG Per Medical Guidelines Carimune IVIG Per Medical Guidelines Flebogamma IVIG Per Medical Guidelines Gammagard IVIG/SCIG Per Medical Guidelines
More informationIVIG (intravenous immunoglobulin) Bivigam, Carimune NF, Flebogamma, Gammagard, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Octagam, Privigen
Pre - PA Allowance None Prior-Approval Requirements Diagnoses Patient must have ONE of the following documented indications: 1. Primary Immunodeficiency Disease (PID) with ONE of the a. Hypogammaglobulinemia,
More informationIntravenous Immune Globulins (IVIG)
Intravenous Immune Globulins (IVIG) Intravenous Immune Globulin (IVIG): Bivigam, Carimune NF, Flebogamma DIF, Gammagard Liquid, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Octagam, and Privigen Subcutaneous
More informationImmune Globulin. Prior Authorization
MB9423 Covered Service: Yes when meets criteria below Prior Authorization Required: Additional Information: Yes as shown below Requires prior authorization through Navitus and is considered medically appropriate
More informationIMMUNE GLOBULIN THERAPY
IMMUNE GLOBULIN THERAPY Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and
More informationPrimary Diagnosis: Diagnosis Code(s) (if known): Individual s Weight (lbs) (kg)
Request Date: Initial Request Buy and Bill Individual s Name: Insurance Identification Number: Subsequent request Date of Birth: Individual s Phone Number: Primary Diagnosis: Diagnosis Code(s) (if known):
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Immunoglobulin for Bacterial Infection in HIV Positive Children Reference Number: CP.CPA.42 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Commercial Revision Log See
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Immunoglobulin for Parvovirus B19 Infection Reference Number: CP.CPA.90 Effective Date: 11.16.16 Last Review Date: 08.17 Line of Business: Commercial Revision Log See Important Reminder
More informationImmune Globulins Drug Class Prior Authorization Protocol
Line of Business: Medi-Cal Effective Date: May 18, 2016 Renewal Date: August 16, 2017 Immune Globulins Drug Class Prior Authorization Protocol This policy has been developed through review of medical literature,
More informationPOLICIES AND PROCEDURE MANUAL
POLICIES AND PROCEDURE MANUAL Policy: MBP 4.0 Section: Medical Benefit Pharmaceutical Policy Subject: Intravenous Immune Globulin (IVIG) I. Policy: Intravenous Immune Globulin (IVIG) II. Purpose/Objective:
More informationImmune Globulin Therapy
PHARMACY / MEDICAL POLICY 8.01.503 Immune Globulin Therapy BCBSA Ref. Policy: 8.01.05 Effective Date: Jan. 1, 2019 Last Revised: Dec. 19, 2018 Replaces: N/A RELATED MEDICAL POLICIES: 5.01.550 Pharmacotherapy
More information3. Does the patient have a diagnosis of warm-type autoimmune hemolytic anemia?
Pharmacy Prior Authorization AETA BETTER HEALTH FLORIDA IVIG (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax
More informationImmune Globulins Last Review Date: September 13, 2016 Number: MG.MM.PH.17av2 Medical Guideline Disclaimer Definition
Last Review Date: September 13, 2016 Number: MG.MM.PH.17av2 Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth
More informationClinical Policy: Immune Globulins Reference Number: ERX.SPMN.129
Clinical Policy: Immune Globulins Reference Number: ERX.SPMN.129 Effective Date: 03/14 Last Review Date: 09/16 Revision Log Coding_Implications See Important Reminder at the end of this policy for important
More informationLocal Coverage Determination (LCD) for Intravenous Immune Globulin (L29205)
Local Coverage Determination (LCD) for Intravenous Immune Globulin (L29205) Contractor Information Contractor Name First Coast Service Options, Inc. Back to Top Contractor Number 09102 Contractor Type
More informationOriginal Policy Date
MP 8.01.04 Immune Globulin Therapy Medical Policy Section Therapy Issue 12/2013 Original Policy Date 12/2013 Last Review Status/Date Reviewed with literature search/12/2013 Return to Medical Policy Index
More informationBortezomib (Velcade)
Bortezomib (Velcade) Policy Number: Original Effective Date: MM.04.003 03/09/2004 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 06/01/2015 Section: Prescription Drugs Place(s)
More informationErythropoiesis Stimulating Agents (ESA)
Erythropoiesis Stimulating Agents (ESA) Policy Number: Original Effective Date: MM.04.008 04/15/2007 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 06/01/2015 Section: Prescription
More informationIntravenous Immunoglobulin (IVIG)*
Subject: Intravenous Immunoglobulin (IVIG)* Updated: December 9, 2008 Department(s): Policy: Objective: Procedure: Utilization Management The use of intravenous immunoglobulin is reimbursable under Plans
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Immunoglobulin for Paraneoplastic Disorders Reference Number: CP.CPA.89 Effective Date: 11.16.16 Last Review Date: 08.17 Line of Business: Commercial Revision Log See Important Reminder
More informationContinuous Glucose Monitoring System
Continuous Glucose Monitoring System Policy Number: Original Effective Date: MM.02.003 03/13/2001 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 04/01/2016 Section: DME Place(s)
More informationContinuous Glucose Monitoring System
Continuous Glucose Monitoring System Policy Number: Original Effective Date: MM.02.003 03/13/2001 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 4/1/2018 Section: DME Place(s)
More informationIMMUNE GLOBULIN (IVIG AND SCIG)
IMMUNE GLOBULIN (IVIG AND SCIG) UnitedHealthcare Community Plan Medical Benefit Drug Policy Policy Number: CS2018D0035X Effective Date: March 1, 2018 Table of Contents Page INSTRUCTIONS FOR USE... 1 BENEFIT
More informationContinuous Glucose Monitoring System
Continuous Glucose Monitoring System Policy Number: Original Effective Date: MM.02.003 03/13/2001 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 04/01/2017 Section: DME Place(s)
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Reference Number: CP.CPA.142 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Commercial Revision Log See Important Reminder at the end of this policy for important regulatory
More informationCigna Drug and Biologic Coverage Policy
Cigna Drug and Biologic Coverage Policy Subject Immune Globulin Effective Date 10/15/2017 Next Review Date.10/15/2018 Coverage Policy Number..5026 Table of Contents Coverage Policy... 1 General Background...
More informationIMMUNE GLOBULIN (IVIG AND SCIG)
IMMUNE GLOBULIN (IVIG SCIG) Policy Number: 2017D0035U Effective Date: February 1, 2017 Table of Contents Page INSTRUCTIONS FOR USE... 1 BENEFIT CONSIDERATIONS... 1 COVERAGE RATIONALE... 2 U.S. FOOD DRUG
More informationRemicade (Infliximab)
Remicade (Infliximab) Policy Number: Original Effective Date: MM.04.016 11/18/2003 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 07/26/2013 Section: Prescription Drugs Place(s)
More informationClinical Policy: Immune Globulins Reference Number: CP.PHAR.103 Effective Date: 08/12 Last Review Date: 09/17 Line of Business: Medicaid
Clinical Policy: Reference Number: CP.PHAR.103 Effective Date: 08/12 Last Review Date: 09/17 Line of Business: Medicaid Coding Implications Revision Log See Important Reminder at the end of this policy
More informationFrom: Plasma Protein Therapeutics Association (PPTA)
Polyvalent Human Immunoglobulins Application for reinstatement to the WHO Model List From: Plasma Protein Therapeutics Association (PPTA) 1. Summary statement of the proposal for inclusion, change or deletion
More informationMedical Policy An independent licensee of the Blue Cross Blue Shield Association
Intravenous and Subcutaneous Immune Globulin Therapy Page 1 of 100 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Intravenous and Subcutaneous Immune Globulin Therapy
More informationInsulin Pumps - External
Insulin Pumps - External Policy Number: Original Effective Date: MM.01.004 04/01/2011 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 04/01/20174/1/2018 Section: DME Place(s) of
More informationLow-Molecular-Weight Heparin
Low-Molecular-Weight Heparin Policy Number: Original Effective Date: MM.04.019 10/15/2007 Line(s) of Business: Current Effective Date: HMO; PPO 10/28/2011 Section: Prescription Drugs Place(s) of Service:
More informationBevacizumab (Avastin)
Bevacizumab (Avastin) Policy Number: Original Effective Date: MM.04.001 09/14/2004 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST 03/01/2014 Section: Prescription Drugs Place(s) of Service:
More informationBrand Generic J-Code 1 Billable. Exclusion Criteria. Information and Criteria. Unit
Affinity Health Plan Department Of Pharmacy (Medicaid, Child Health Plus, Family Health Plus, Medicare Part B) **Medications Requiring Authorization under Medical Benefit** Click Here For Medication Authorization
More informationMedical Policy An independent licensee of the Blue Cross Blue Shield Association
Intravenous and Subcutaneous Immune Globulin Therapy Page 1 of 68 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Intravenous and Subcutaneous Immune Globulin Therapy
More informationCorporate Medical Policy
Corporate Medical Policy File Name: Origination: Last CAP Review: Next CAP Review: Last Review: immune_globulin_therapy 07/1994 2/2017 2/2018 2/2017 Description of Procedure or Service Human immunoglobulin
More informationImmune Globulin Therapy
Applies to all products administered or underwritten by Blue Cross and Blue Shield of Louisiana and its subsidiary, HMO Louisiana, Inc.(collectively referred to as the Company ), unless otherwise provided
More informationPolicy. Medical Policy Manual Approved: Do Not Implement Until 1/31/19. Intravenous Immune Globulin (IVIG) Therapy
Intravenous Immune Globulin (IVIG) Therapy NDC CODE(S) 59730-6502-XX - Bivigam 5 g protein 59730-6503-XX - Bivigam 10 g protein 44206-0416-XX - Carimune NF 3 g protein 44206-0417-XX - Carimune 6 g protein
More informationSubcutaneous Immune Globulin: Alternative Therapeutic Pathway for Patients With Primary Immunodeficiency
Subcutaneous Immune Globulin: Alternative Therapeutic Pathway for Patients With Primary Immunodeficiency EDUCATIONAL OBJECTIVES Upon completion of this program, participants should be better able to: 1.
More informationGrowth Hormone Therapy
Growth Hormone Therapy Policy Number: Original Effective Date: MM.04.011 05/21/1999 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 05/23/2014 Section: Prescription Drugs Place(s)
More informationCorporate Medical Policy
Corporate Medical Policy File Name: Origination: Last CAP Review: Next CAP Review: Last Review: immune_globulin_therapy 07/1994 2/2017 2/2018 2/2017 Description of Procedure or Service Human immunoglobulin
More informationCLINICAL MEDICAL POLICY
CLINICAL MEDICAL POLICY Policy Name: Rituxan (rituximab) Policy Number: MP-031-MD-DE Responsible Department(s): Medical Management; Clinical Pharmacy Provider Notice Date: 10/01/2017 Issue Date: 11/01/2017
More informationIVIG Immune Globulin Bivigam, Carimune NF, Flebogamma, Gammagard, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Octagam, Privigen
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.20.03 Subject: IVIG Page: 1 of 13 Last Review Date: December 2, 2016 IVIG (intravenous immunoglobulin)
More informationGazyva (obinutuzumab)
Gazyva (obinutuzumab) Line(s) of Business: HMO; PPO; QUEST Integration Medicare Advantage Original Effective Date: 10/01/2015 Current Effective Date: 01/01/201807/01/2018 POLICY A. INDICATIONS The indications
More informationSPECIALTY GUIDELINE MANAGEMENT
POLICY SPECIALTY GUIDELINE MANAGEMENT Intravenous Immune Globulin (IVIG): Bivigam, Carimune NF, Flebogamma DIF, Gammagard Liquid, Gammagard S/D, Gammaked, Gammaplex, Gamunex -C, Octagam, and Privigen I.
More informationIVIG (Intravenous Immune Globulin) SCIG (Subcutaneous Immune Globulin)
Phone: (800) 244-6224 Fax: (855) 840-1678 IVIG (Intravenous Immune Globulin) SCIG (Subcutaneous Immune Globulin) Notice: Please be sure to complete this form in its entirety. Missing information makes
More informationOxygen and Oxygen Equipment
Oxygen and Oxygen Equipment Policy Number: Original Effective Date: MM.01.008 12/01/2010 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST 09/01/2013 Section: DME Place(s) of Service: Home I.
More informationNegative Pressure Wound Therapy (NPWT)
Negative Pressure Wound Therapy (NPWT) Policy Number: Original Effective Date: MM.01.005 11/19/1999 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST 01/01/2015 Section: DME Place(s) of Service:
More informationPhotochemotherapy MM /09/2004. HMO; PPO; QUEST Integration June 1, 2016 Section: Medicine Place(s) of Service: Home; Office
Photochemotherapy Policy Number: Original Effective Date: MM.02.015 11/09/2004 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration June 1, 2016 Section: Medicine Place(s) of Service:
More informationPOLICY Document for Intravenous Immune Globulin (IVIG)
'-..-Ct.I t.j..l.l ~L..,r. V. Family of health care plans CV$ Caremark POLICY Document for Intravenous Immune Globulin (IVIG) The overall objective of this policy is to support the appropriate and cost
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Immunoglobulin for Aneurysm in Kawasaki Syndrome Reference Number: CP.CPA.86 Effective Date: 11.16.16 Last Review Date: 08.17 Line of Business: Medicaid Medi-Cal Revision Log See Important
More informationModular Program Report
Modular Program Report The following report(s) provides findings from an FDA initiated query using its Mini Sentinel pilot. While Mini Sentinel queries may be undertaken to assess potential medical product
More informationVelcade (bortezomib)
Velcade (bortezomib) Line(s) of Business: HMO; PPO; QUEST Integration Medicare Advantage Original Effective Date: 03/09/2004 Current Effective Date: 03/01/2018 POLICY A. INDICATIONS The indications below
More informationMEDICAL POLICY IMMUNE GLOBULIN MP POLICY TITLE POLICY NUMBER
Original Issue Date (Created): September 20, 2002 Most Recent Review Date (Revised): June 4, 2013 Effective Date: October 1, 2013 I. POLICY Intravenous Immune globulin (IVIg) Therapy IVIg may be considered
More informationMEDICAL POLICY No R10 INFUSION SERVICES & EQUIPMENT
INFUSION SERVICES & EQUIPMENT Effective Date: August 1, 2017 Review Dates: 10/95, 12/99, 12/01, 11/02, 11/03, 11/04, 10/05, 10/06, 10/07, 10/08, 10/09, 4/10, 4/11, 4/12, 4/13, 5/14, 5/15, 2/16, 2/17, 5/17
More informationVelcade (bortezomib)
Velcade (bortezomib) Line(s) of Business: HMO; PPO; QUEST Integration Akamai Advantage Original Effective Date: 03/09/2004 Current Effective Date: 05/01/2017 POLICY A. INDICATIONS The indications below
More informationAUTOIMMUNE DISORDERS IN THE ACUTE SETTING
AUTOIMMUNE DISORDERS IN THE ACUTE SETTING Diagnosis and Treatment Goals Aimee Borazanci, MD BNI Neuroimmunology Objectives Give an update on the causes for admission, clinical features, and outcomes of
More informationThe University of Mississippi Medical Center The University of Mississippi Health Care. Pharmacy and Therapeutics Committee Medication Use Evaluation
The University of Mississippi Medical Center The University of Mississippi Health Care Pharmacy and Therapeutics Committee Medication Use Evaluation June 2012 Objective The goal of this medication use
More informationCOMMON VARIABLE IMMUNODEFICIENCY
COMMON VARIABLE IMMUNODEFICIENCY This booklet is intended for use by patients and their families and should not replace advice from a clinical immunologist. 1 COMMON VARIABLE IMMUNODEFICIENCY Also available
More informationExtracorporeal Membrane Oxygenation (ECMO)
Extracorporeal Membrane Oxygenation (ECMO) Policy Number: Original Effective Date: MM.12.006 05/16/2006 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 01/01/2017 Section: Other/Miscellaneous
More informationOxygen and Oxygen Equipment
Oxygen and Oxygen Equipment Policy Number: Original Effective Date: MM.01.008 12/01/2010 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 08/25/2017 Section: DME Place(s) of Service:
More informationExtracorporeal Membrane Oxygenation (ECMO)
Extracorporeal Membrane Oxygenation (ECMO) Policy Number: Original Effective Date: MM.12.006 05/16/2006 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 11/01/2014 Section: Other/Miscellaneous
More informationClinical Policy Title: Intravenous immunoglobulin
Clinical Policy Title: Intravenous immunoglobulin Clinical Policy Number: 00.02.11 Effective Date: April 1, 2015 Initial Review Date: November 19, 2014 Most Recent Review Date: May 1, 2018 Next Review
More informationImmune Globulin. Clinical Overview Program BioScrip Inc. All rights reserved BioScrip Inc. All rights reserved.
Immune Globulin Clinical Overview Program Objectives Discuss Autoimmune disorders Describe IG structure, properties and clinical implications Discuss IG product usage, storage and mixing guidelines Discuss
More informationIntensity Modulated Radiation Therapy (IMRT)
Intensity Modulated Radiation Therapy (IMRT) Policy Number: Original Effective Date: MM.05.006 03/09/2004 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 03/01/2015 Section: Radiology
More informationBone (Mineral) Density Studies
Bone (Mineral) Density Studies Policy Number: Original Effective Date: MM.05.002 03/23/2001 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST 03/01/2014 Section: Radiology Place(s) of Service:
More informationApplications of this product for conditions other than those addressed in this policy are considered OFF-LABEL and are not addressed in this policy.
Subject: Intravenous infusion Immune Globulin (IVIg) Original Effective Date: 12/6/2007 Policy Number: MCP-043 Revision Date(s): 4/27/2011;1/22/2013 Review Date(s): 4/27/2011;1/22/2013, 12/16/2015; 3/30/2016;
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Promacta) Reference Number: CP.PHAR.180 Effective Date: 03.01.16 Last Review Date: 02.18 Line of Business: Commercial, Health Insurance Marketplace, Medicaid Revision Log See Important
More informationCommittee Approval Date: May 9, 2014 Next Review Date: May 2015
Medication Policy Manual Policy No: dru248 Topic: Benlysta, belimumab Date of Origin: May 13, 2011 Committee Approval Date: May 9, 2014 Next Review Date: May 2015 Effective Date: June 1, 2014 IMPORTANT
More informationSCIG: (Immune globulin SQ) Hizentra, Vivaglobin, Gammagard Liquid, Gamunex- C, Gammaked, Hyqvia Page 1 of 6
Moda Health Plan, Inc. Medical Necessity Criteria Subject: Origination Date: 04/1 Revision Date(s): 02/16 Developed By: Medical Criteria Committee Effective Date: 0/01/1 SCIG: (Immune globulin SQ) Hizentra,
More informationLung-Volume Reduction Surgery ARCHIVED
Lung-Volume Reduction Surgery ARCHIVED Policy Number: Original Effective Date: MM.06.008 04/15/2005 Line(s) of Business: Current Effective Date: PPO; HMO; QUEST 03/22/2013 Section: Surgery Place(s) of
More informationForm 2033 R3.0: Wiskott-Aldrich Syndrome Pre-HSCT Data
Key Fields Sequence Number: Date Received: - - CIBMTR Center Number: CIBMTR Recipient ID: Has this patient's data been previously reported to USIDNET? USIDNET ID: Today's Date: - - Date of HSCT for which
More informationIntensity Modulated Radiation Therapy (IMRT)
Intensity Modulated Radiation Therapy (IMRT) Policy Number: Original Effective Date: MM.05.006 03/09/2004 Line(s) of Business: Current Effective Date: HMO; PPO 06/24/2011 Section: Radiology Place(s) of
More informationPhotochemotherapy MM /09/2004. HMO; PPO; QUEST Integration 08/25/2017 Section: Medicine Place(s) of Service: Home; Office
Photochemotherapy Policy Number: Original Effective Date: MM.02.015 11/09/2004 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 08/25/2017 Section: Medicine Place(s) of Service:
More informationPerjeta (pertuzumab)
Perjeta (pertuzumab) Line(s) of Business: HMO; PPO; QUEST Integration Medicare Advantage Original Effective Date: 10/01/2015 Current Effective Date: 01/01/201809/16/2018 POLICY A. INDICATIONS The indications
More informationClinical Policy: Eltrombopag (Promacta) Reference Number: ERX.SPA.71 Effective Date:
Clinical Policy: (Promacta) Reference Number: ERX.SPA.71 Effective Date: 10.01.16 Last Review Date: 11.18 Revision Log See Important Reminder at the end of this policy for important regulatory and legal
More informationPosterior Tibial Nerve Stimulation
Posterior Tibial Nerve Stimulation Policy Number: Original Effective Date: MM.02.025 01/01/2015 Lines of Business: Current Effective Date: HMO; PPO; QUEST Integration 02/01/2015 Section: Medicine Place(s)
More informationNOTE: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material that is copyrighted by
NOTE: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material that is copyrighted by the American Medical Association. You are forbidden
More informationPhysical Therapy MM /15/2003
Physical Therapy Policy Number: Original Effective Date: MM.09.005 07/15/2003 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 06/23/2017 Line(s) of Business Excluded: Federal Employee
More informationDRUG USE EVALUATION: OFF-LABEL USE OF IMMUNE GLOBULIN G
G The Immunoglobulin G (IgG) drug class evidence review on products identified strong evidence to support the use of intravenous and subcutaneous IgG for primary immunodeficiency and little evidence preferring
More informationBariatric Surgery MM /11/2001. HMO; PPO; QUEST 05/01/2012 Section: Surgery Place(s) of Service: Outpatient; Inpatient
Bariatric Surgery Policy Number: Original Effective Date: MM.06.003 09/11/2001 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST 05/01/2012 Section: Surgery Place(s) of Service: Outpatient;
More informationModular Program Report
Modular Program Report The following report(s) provides findings from an FDA initiated query using its Mini Sentinel pilot. While Mini Sentinel queries may be undertaken to assess potential medical product
More informationTorisel (temsirolimus)
Torisel (temsirolimus) Line(s) of Business: HMO; PPO; QUEST Integration Medicare Advantage Original Effective Date: 10/01/2015 Current Effective Date: 11/1/2017 POLICY A. INDICATIONS The indications below
More informationPositive Airway Pressure and Oral Devices for the Treatment of Obstructive Sleep Apnea
Positive Airway Pressure and Oral Devices for the Treatment of Obstructive Sleep Apnea Policy Number: Original Effective Date: MM.01.009 11/01/2009 Line(s) of Business: Current Effective Date: HMO; PPO
More informationWiskott-Aldrich Syndrome
chapter 7 Wiskott-Aldrich Syndrome Wiskott-Aldrich syndrome is a primary immunodeficiency disease involving both T- and B-lymphocytes. In addition, the blood cells that help control bleeding, called platelets
More informationPositive Airway Pressure and Oral Devices for the Treatment of Obstructive Sleep Apnea
Positive Airway Pressure and Oral Devices for the Treatment of Obstructive Sleep Apnea Policy Number: Original Effective Date: MM.01.009 11/01/2009 Line(s) of Business: Current Effective Date: HMO; PPO;
More informationCigna Medical Coverage Policy
Cigna Medical Coverage Policy Subject Immune Globulin Subcutaneous [Human] Effective Date... 5/15/2012 Next Review Date.5/15/2013 Coverage Policy Number... 8004 Table of Contents Coverage Policy... 1 General
More informationIncontinence Supplies
Incontinence Supplies Policy Number: Original Effective Date: MM.12.020 07/01/2015 Lines of Business: Current Effective Date: QUEST Integration 09/28/2018 Section: Other/Miscellaneous Place(s) of Service:
More informationDepartment of Origin: Pharmacy. Approved by: Pharmacy and Therapeutics Quality Management Subcommittee Effective Date: Date approved: 11/09/16
Reference #: PC/I002 Page: 1 of 9 PRODUCT APPLICATION: PreferredOne Administrative Services, Inc. (PAS) ERISA PreferredOne Administrative Services, Inc. (PAS) Non-ERISA PreferredOne Community Health Plan
More informationElements for a Public Summary
VI.2 VI.2.1 Elements for a Public Summary Overview of disease epidemiology Nanogam is intended to be used for the treatment of diseases in patients who are suffering from a shortage of immunoglobulins
More informationIntravenous Immune Globulins (immune globulin) Document Number: MODA-0071
Intravenous Immune Globulins (immune globulin) Document Number: MODA-0071 Last Review Date: 09/19/2017 Date of Origin: 07/20/2010 Dates Reviewed: 09/2010, 12/2010, 02/2011, 03/2011, 06/2011, 09/2011, 10/2011,
More informationRITUXAN (rituximab), NONONCOLOGIC USES
RITUXAN (rituximab), NONONCOLOGIC USES Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical
More information