Mountain State Medical Policy Bulletin |
Section: | Injections |
Number: | I-14 |
Topic: | Intravenous Immune Globulin |
Effective Date: | August 1, 2005 |
Issued Date: | August 1, 2005 |
Date Last Reviewed: | 07/2005 |
Indications and Limitations of Coverage
Coverage for Intravenous Immune Globulin (IVIG) is determined according to individual or group customer benefits. This policy only addresses non-specific pooled preparations of intravenous immune globulin. The policy does not address other immunoglobulin preparations that are specifically used for passive immunization to prevent or attenuate infection with specific viral diseases. Refer to Medical Policy Bulletin I-8 for information on Immunizations. Intravenous immune globulin is indicated only if standard approaches have failed, become intolerable, or are contraindicated. Intravenous immune globulin is eligible for the conditions listed below:
Description Immune globulin is one of five closely-related proteins found in the human body. These proteins are capable of acting as antibodies. Gammaglobulin is an intravenous or intramuscular drug which has IgG antibodies and is used for the prevention and treatment of specific disease. Intravenous immune globulin (IVIG) is an antibody-containing solution obtained from the pooled plasma of healthy blood donors, containing antibodies to greater than 10 million antigens. IVIG may also be known under the following names:
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90283 | 90291 | J0850 | J1563 | J1564 | Q9941 |
Q9942 | Q9943 | Q9944 |
PRN References 02/1998, Immune globulin/gamma globulin eligibility |
Treatment of Multiple Sclerosis: Recent Trials and Future Perspectives, Current Opinion in Neurology, Vol. 12, No. 3, 06/99 Immune Globulin Intravenous (Human), USPDI - Vol. I, Edition 22, 2002, Micromedex, Inc. |