Intravenous Immune Globulin Injection

IVIG is covered for the policy’s list of FDA‑approved and compendial off‑label indications (e.g., primary/secondary humoral immunodeficiencies, ITP, CIDP, MMN, Kawasaki disease, GBS, myasthenia gravis, transplant ABMR, post‑exposure measles/varicella prophylaxis, and other listed autoimmune, neurologic and infection‑related conditions) and is not covered for uses outside those FDA‑approved or compendial indications. Coverage requires documentation of the specific diagnosis, required laboratory thresholds/antibody responses (e.g., IgG cutoffs), prior therapy trials or documented contraindications, appropriate specialist prescription/consultation, indication‑specific diagnostic/timing criteria, and evidence of benefit for reauthorization with varying approval durations.

"Nerve conduction study results, motor nerve biopsy or MRI neurography for MMN diagnostic support"