Intravenous Immune Globulin Injection

This Evicore policy covers IVIG for listed FDA‑approved and compendial off‑label indications (e.g., primary/secondary humoral immunodeficiencies, ITP, CIDP, MMN, Kawasaki disease, ABMR, autoimmune blistering diseases, GBS, myasthenia gravis, LEMS, MS relapse, PRCA, transplant desensitization, post‑exposure measles/varicella, etc.) and excludes use outside those approved/compendial indications. Coverage requires indication‑specific diagnostic and laboratory evidence (IgG troughs, impaired antibody response, electrodiagnostic studies, platelet counts, etc.), prescription/consultation by specified specialists, trials of prior therapies or documented contraindications, adherence to dosing/approval durations, and objective clinical benefit for reauthorization.

"GBS specific limitation: no more than 2 courses of therapy; subsequent courses must be at least 3 weeks after the first."