90284
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- For initial therapy: documented diagnosis submitted.
- For initial therapy: medical records documenting history and physical examination documenting severity of condition (including frequency and severity of infections where applicable).
- For initial therapy: laboratory results or diagnostic evidence supporting the indication for which immune globulin is requested.
- For initial therapy: prescriber attestation that dosing is in accordance with FDA-approved labeling or, for indications without FDA dosing, that published clinical evidence supports the dosing.
Key Coverage Criteria
- Acute disseminated encephalomyelitis (ADEM)
- Myasthenia gravis — exacerbation and refractory generalized MG (with criteria; maintenance for refractory cases per guidance)
- Neuromyelitis optica spectrum disorder (NMOSD) — treatment when criteria met including AQP4-IgG testing and prior therapy failures
- Paraproteinemic neuropathy
- Autoimmune bullous diseases (pemphigus vulgaris, pemphigus foliaceus, bullous pemphigoid, mucous membrane (cicatricial) pemphigoid, epidermolysis bullosa acquisita, pemphigoid gestationis, linear IgA bullous dermatosis)
- Toxic epidermal necrolysis or Stevens-Johnson syndrome
9 Active Policies
UHC-POL-immune-globulin-ivig-scig — Immune Globulin (IVIG and SCIG)
UHC-POL-provider-administered-drugs-soc — Provider Administered Drugs – Site of Care
UMR-POL-UMR-immune-globulin-ivig-scig — Immune Globulin (IVIG and SCIG)
UMR-POL-UMR-provider-administered-drugs-soc — Provider Administered Drugs – Site of Care
Related Codes
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