J1572, Injection, immune globulin, (flebogamma/flebogamma dif), intravenous,
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- The medical record must include the ordering provider's assessment related to the complaint, relevant medical history, results of pertinent tests/procedures, and signed and dated office visit or operative reports.
- Required documentation of medical necessity includes history and physical, a supporting physician rationale current within the last 12 months, and physician orders not more than 30 days old specifying dose, frequency, administration route and duration, with office/progress notes documenting necessity for initiation and continuation.
- An accurate weight in kilograms must be documented prior to each infusion because dosing is mg/kg.
- Medication administration records and documentation of the patient's response to prior infusions must accompany each order for ongoing therapy.
- For CVID claims, the record must include initial IgG levels, Pneumovax vaccination and pre/post pneumococcal antibody titers, dual diagnoses for the underlying condition, and a statement regarding lack of response to protein antigen.
- For HIV with ITP claims, the medical record must document a platelet count less than 30,000 and active bleeding supported by applicable laboratory results.
Key Coverage Criteria
- IVIG is covered for patients with common variable immunodeficiency (CVID) when initial presenting IgG levels, evidence of Pneumovax vaccination, and pre- and post-vaccine pneumococcal antibody titers demonstrate inability to produce an antibody response to protein or carbohydrate antigens, and documentation includes dual diagnoses and a statement of lack of response to protein antigen.
- IVIG is covered for patients with HIV disease and immune thrombocytopenic purpura (ITP) when the medical record documents a platelet count less than 30,000 and active bleeding supported by laboratory results.
- IVIG is covered for immunodeficient individuals with recurrent or chronic bacterial sinusitis when the record documents findings diagnostic of or highly suggestive of bacterial sinus infection (for example fever, unilateral purulent nasal discharge, unilateral facial pain) and documents prolonged and/or recurrent antibiotic therapy.
- IVIG is covered for stiff-man syndrome when the patient is under the care of a physician competent in diagnosis, meets the defined diagnostic criteria, has failed conservative therapy (e.g., benzodiazepines), and documentation shows objective response after initial treatment for continued coverage.
- IVIG is covered when the treating physician documents medical necessity for initiation or continuation, including history and physical, a current supporting physician rationale (within 12 months), and physician orders (<=30 days old) specifying dose, frequency, administration route and duration with office/progress notes documenting response.
- Billing and coding guidance in this article applies when immune globulin use meets the reasonable and necessary coverage criteria established in LCD L35093.
20 Active Policies
CGS-L35891, Intravenous Immune Globulin
J15
CGS-L38268, Immune Thrombocytopenia (ITP) Therapy
J15
A57554, Billing and Coding: Immune Globulins
J5
WPS-L34771, Immune Globulins
J8
FIRST_COAST-L34007, Immune Globulin
J9
A57778, Billing and Coding: Immune Globulin
J9
NOVITAS-L35093, Immune Globulin
JH
NGS-L40181, Off-Label Use of Intravenous Immune Globulin (IVIG)
JK
A56786, Billing and Coding: Immune Globulin
JL
BCBSMT-RX504.003, Immunoglobulin Therapy
BCBSMT-ADM1001.034, Specialty Medication Administration Site of Care
BCBSNM-RX504.003, Immunoglobulin Therapy
BCBSNM-ADM1001.034, Specialty Medication Administration Site of Care
BCBSOK-RX504.003, Immunoglobulin Therapy
BCBSOK-ADM1001.034, Specialty Medication Administration 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
SUREST-POL-SUREST-immune-globulin-ivig-scig, Immune Globulin (IVIG and SCIG)
A56779, Billing and Coding: Intravenous Immune Globulin
CIGNA-0447, Autism Spectrum Disorders/Pervasive Developmental Disorders: Assessment and Treatment
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