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Immune globulin therapy

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.

Administrative process

Prior authorization is required for Immune globulin therapy, except for the conditions listed below.

Immune globulin therapy is generally covered subject to the indications listed below, and per your plan documents.

Immunologic diagnoses

  1. Primary immunodeficiencies including:
    1. B-cell immune deficiencies including common variable immune deficiency, X-linked immunodeficiency, and Hyper-IgM syndromes
    2. Severe combined immunodeficiencies (SCID)
    3. Wiskott-Aldrich syndrome
    4. Hyperimmunglobulin E syndrome
    5. Congenital agammaglobulinemia
  2. Secondary immunodeficiencies including:
    1. Acquired hypogammagloulin conditions including B-cell chronic lymphocytic leukemia and multiple myeloma
    2. Prevention of acute graft versus host disease (GVHD) after transplantation
    3. Prevention of infection in transplant recipients (e.g., solid organ, stem cell, bone marrow)

Neurologic diagnoses

  1. Chronic inflammatory demyelinating polyneuritis (CIDP)
  2. Myasthenia gravis
  3. Lambert-Eaton myasthenic syndrome
  4. Guillain-Barre syndrome
  5. Multifocal motor neuropathy

Other diagnoses

  1. Acute and chronic immune-medicated (idiopathic) thrombocytopenia purpura (ITP)
  2. HIV-associated thrombocytopenia
  3. Kawasaki disease when used in combination with aspirin
  4. Dermatomyositis and polymyositis when first-line oral agents have failed or are contraindicated
  5. Pemphigus when corticosteroids have failed or are contraindicated

Use of immune globulin for all other diagnoses requires review for medical necessity.

Immune globulin therapy provides antibodies against a wide variety of bacterial and viral antigens. It is prepared from human blood plasma.

Some preparations have received FDA approval for subcutaneous administration. These include: Vivagloblin (not currently marketed), Hizentra, Gamunex-C.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Code Description Preparation NDC Codes
90283 Immune Globulin (IgIV) human, for intravenous use (Code price is per 500 mg) for CPT billing requirements only

Bivigam

59730650301
59730650201

Carimune NF 44206041812
44206041603
44206041706
Flebogamma 61953000301
61953000304
61953000302
61953000303
Flebogamma DIF 61953000401
61953000404
61953000402
61953000403
61953000405
61953000501
61953000502
61953000503
Gammagard S/D 00944262004
00944262002
00944262003
00944265504
00944265503
00944270002
00944270003
00944270004
00944270005
00944270006
00944270007
Gammaked 76125090001
76125090010
76125090025
76125090020
76125090050
Gammaplex 64208823401
64208823402
64208823403
Gamunex 13533064512
13533064571
13533064515
13533064524
13533064520
Gamunex-C 13533080012
13533080071
13533080015
13533080024
13533080020
Privigen 44206043710
44206043820
44206043605
90284 Immune Globulin (SCIg), human, for use in subcutaneous infusions, 100 mg, each for CPT billing requirements only Gammagard S/D 00944262004
00944262002
00944262003
00944265504
00944265503
00944270002
00944270003
00944270004
00944270005
00944270006
00944270007
Gammaked 76125090001
76125090010
76125090025
76125090020
76125090050
Gamunex-C 13533080012
13533080071
13533080015
13533080024
13533080020
Hizentra 44206045101
44206045202
44206045404
J1459 Injection, immune globulin (Privigen), intravenous, non-lyophilized (e.g., liquid), 500mg Privigen 44206043710
44206043820
44206043605

J1460

Injection, gamma globulin, intramuscular, 1 cc

Gamastan S/D

54569582800
13533063504
13533063512
13533063513
13533063540

J1556

Injection, immune globulin (Bivigam), 500 mg

Bivigam

59730650301
59730650201

J1557 Injection, immune globulin, (Gammaplex), intravenous, non-lyophilized (e.g., liquid), 500 mg Gammaplex 64208823401
64208823402
64208823403
J1559 Injection, immune globulin (Hizentra), 100 mg Hizentra 44206045101
44206045202
44206045404
J1561 Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), intravenous, non-lyophilized (e.g., liquid), 500 mg Gamunex 13533064512
13533064571
13533064515
13533064524
13533064520
Gamunex-C 13533080012
13533080071
13533080015
13533080024
13533080020
Gammaked 76125090001
76125090010
76125090025
76125090020
76125090050
J1566 Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg Carimune NF 44206041812
44206041603
44206041706
Gammagard S/D 00944262004
00944262002
00944262003
00944265504
00944265503
J1568 Injection, immune globulin, (Octagam), intravenous, non-lyophilized (e.g., liquid), 500 mg Octagam 68209084301
67467084301
67467084305
J1569 Injection, immune globulin, (Gammagard), intravenous, non-lyophilized, (e.g., liquid), 500 mg Gammagard 00944270002
00944270005
00944270003
00944270006
00944270007
00944270004
J1572 Injection, Immune globulin, (Flebogamma/Flebogamma DIF), intravenous, non-lyophilized (e.g., liquid), 500 mg Flebogamma 61953000301
61953000304
61953000302
61953000303
Flebogamma DIF 61953000401
61953000404
61953000402
61953000403
61953000405
61953000501
61953000502
61953000503
J1599 Injection, immune globulin, intravenous, non-lyophilized (e.g., liquid), not otherwise specified, 500 mg    


ICD-9 Codes
042 - Human immunodeficiency virus (HIV)
203.00 - Multiple myeloma, without mention of having achieved remission
203.01 - Multiple myeloma in remission
203.02 - Multiple myeloma, in relapse
204.10 - Chronic lymphoid leukemia, without mention of having achieved remission
204.11 - Chronic lymphoid leukemia in remission
204.12 - Chronic lymphoid leukemia, in relapse
279.00 - Unspecified hypogammaglobulinemia
279.02 - Selective IgM immunodeficiency
279.03 - Other selective immunoglobulin deficiencies
279.04 - Congenital hypogammaglobulinemia
279.05 - Immunodeficiency with increased IgM
279.06 - Common variable immunodeficiency
279.09 - Other, deficiency of humoral immunity
279.11 - DiGeorge’s syndrome
279.12 - Wiskott-Aldrich syndrome
279.2 - Combined immunity deficiency
279.51 - Acute graft-versus-host disease
279.53 - Acute on chronic graft-versus-host disease
279.8 - Other specified disorders involving the immune mechanism
283.0 - Autoimmune hemolytic anemias
287.31 - Immune thrombocytopenic purpura
287.32 - Evans’ syndrome
287.41 - Post-transfusion purpura
287.49 - Other secondary thrombocytopenia
357.0 - Acute infective polyneuritis
357.81 - Chronic inflammatory demyelinating polyneuritis
357.89 - Other inflammatory and toxic neuropathy
358.01 - Myasthenia gravis with (acute) exacerbation
358.1 - Myasthenic syndromes in diseases classified elsewhere
358.30 - Lambert-Eaton syndrome, unspecified
358.31 - Lambert-Eaton syndrome in neoplastic disease
358.39 - Lambert-Eaton syndrome in other diseases classified elsewhere
359.89 - Other myopathies
694.4 -Pemphigus
694.5 - Pemphigoid
694.60 - Benign mucous membrane pemphigoid without mention of ocular involvement
694.61 - Benign mucous membrane pemphigoid with ocular involvement
694.8 - Other specified bullous dermatosis
710.3 - Dermatomyositis
710.4 - Polymyositis
V42.81 - Bone marrow replaced by transplant

Please see the Related content section at the right to see a list of ICD-10-CM codes associated with this policy.

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

References

  1. Uptodate.com. www.uptodate.com Accessed 10/21/2011.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.