Aetna · Clinical coverage policy

Aetna Intravenous Immunoglobulins (IVIG) coverage criteria

Aetna covers IVIG (and subcutaneous immunoglobulin) only for a defined list of conditions - primarily primary immunodeficiencies with documented low IgG and impaired vaccine response, plus specific neurologic, hematologic, autoimmune, transplant, and infectious indications - and most require meeting detailed lab thresholds and/or prior failure of standard therapy. Precertification is required for all IVIG/SCIG, and any indication not explicitly listed (including conditions like Alzheimer's, autism, multiple sclerosis, chronic fatigue syndrome, and COVID-19) is considered experimental, investigational, or unproven.

Policy CPB 0206 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0206

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0206 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Intravenous Immunoglobulins (IVIG) (CPT 90283), and what gets it denied?

Path
Aetna covers IVIG (and subcutaneous immunoglobulin) only for a defined list of conditions - primarily primary immunodeficiencies with documented low IgG and impaired vaccine response, plus specific neurologic, hematologic, autoimmune, transplant, and infectious indications - and most require meeting detailed lab thresholds and/or prior failure of standard therapy. Precertification is required for all IVIG/SCIG, and any indication not explicitly listed (including conditions like Alzheimer's, autism, multiple sclerosis, chronic fatigue syndrome, and COVID-19) is considered experimental, investigational, or unproven. Coverage criteria include: Primary immunodeficiency - SCID or congenital agammaglobulinemia: medically necessary when ONE of (a) diagnosis confirmed by genetic/molecular testing; OR (b) pretreatment IgG level < 200 mg/dL; OR (c) absence or very low T cells (CD3 < 300/microliter) or the presence of maternal T cells in the circulation (SCID only); Primary immunodeficiency - Wiskott-Aldrich syndrome, DiGeorge syndrome, or ataxia-telangiectasia: medically necessary when ALL of (a) diagnosis confirmed by genetic/molecular testing (if applicable); (b) history of recurrent bacterial infections (e.g., pneumonia, otitis media, sinusitis, sepsis, gastrointestinal); (c) impaired antibody response to pneumococcal polysaccharide vaccine; Primary immunodeficiency - Common variable immunodeficiency (CVID): medically necessary when ALL of (a) age >= 2 years; (b) other causes of immune deficiency excluded; (c) pretreatment IgG level < 500 mg/dL or >= 2 SD below the mean for age; (d) history of recurrent bacterial infections; (e) impaired antibody response to pneumococcal polysaccharide vaccine; Primary immunodeficiency - Hypogammaglobulinemia (unspecified), IgG subclass deficiency, selective IgA/IgM deficiency, or specific antibody deficiency: medically necessary when ALL of (a) history of recurrent bacterial infections; (b) impaired antibody response to pneumococcal polysaccharide vaccine; AND (c) ANY ONE of the pretreatment lab findings: hypogammaglobulinemia IgG < 500 mg/dL or >= 2 SD below the mean for age; OR selective IgA deficiency IgA < 7 mg/dL with normal IgG/IgM; OR selective IgM deficiency IgM < 30 mg/dL with normal IgG/IgA; OR IgG subclass deficiency IgG1/2/3 >= 2 SD below mean for age on >= 2 occasions, with normal IgG (total) and IgM levels and normal/low IgA levels; OR specific antibody deficiency with normal IgG/IgA/IgM; Primary immunodeficiency - Other predominant antibody deficiency disorders: medically necessary when ALL of (a) history of recurrent bacterial infections; (b) impaired antibody response to pneumococcal polysaccharide vaccine; (c) pretreatment hypogammaglobulinemia IgG < 500 mg/dL or >= 2 SD below the mean for age; Primary immunodeficiency - Other combined immunodeficiency: medically necessary when ALL of (a) diagnosis confirmed by genetic/molecular testing (if applicable); (b) history of recurrent bacterial infections; (c) impaired antibody response to pneumococcal polysaccharide vaccine; Primary immunodeficiency - Continuation of therapy: medically necessary when (a) reduction in frequency of bacterial infections documented; AND EITHER (b) IgG trough levels monitored at least yearly and maintained at or above the lower range of normal for age (when applicable for indication); OR (c) prescriber re-evaluates dose and considers a dose adjustment (when appropriate); Myasthenia gravis - short-term therapy (one month): medically necessary for ONE of (a) worsening weakness (diplopia, ptosis, blurred vision, dysarthria, dysphagia, difficulty chewing, impaired respiration, fatigue, limb weakness); OR (b) acute exacerbations (severe swallowing difficulties, respiratory failure); OR (c) pre-operative management (e.g., prior to thymectomy); Myasthenia gravis - chronic/refractory: medically necessary when patient has tried and failed 2 or more standard therapies (e.g., corticosteroids, azathioprine, cyclosporine, mycophenolate mofetil, rituximab); Chronic inflammatory demyelinating polyneuropathy (CIDP) - initial therapy: medically necessary when ALL of (a) disease course is progressive or relapsing/remitting for 2 months or longer; (b) moderate to severe functional disability; (c) diagnosis confirmed by electrodiagnostic studies; Chronic inflammatory demyelinating polyneuropathy (CIDP) - continued treatment: medically necessary when ALL of (a) significant improvement in disability and maintenance since initiation; (b) IVIG or SCIG is being used at the lowest effective dose and frequency; Dermatomyositis or polymyositis - initial therapy: medically necessary when member has AT LEAST FOUR of (proximal muscle weakness of upper/lower extremity or trunk; elevated serum creatine kinase or aldolase; muscle pain on grasping or spontaneous pain; myogenic changes on EMG; positive anti-synthetase antibodies anti-Jo-1; non-destructive arthritis or arthralgias; systemic inflammatory signs fever > 37C axilla or elevated CRP or ESR > 20 mm/h by the Westergren method; pathological findings compatible with inflammatory myositis (inflammatory infiltration of skeletal muscle / active regeneration may be seen)) AND EITHER standard first-line (corticosteroids) and second-line (immunosuppressants) treatments tried but unsuccessful or not tolerated; OR member unable to receive standard therapies due to contraindication/clinical reason; Dermatomyositis or polymyositis - continued therapy: medically necessary when significant improvement in disability and maintenance since initiation; Idiopathic thrombocytopenic purpura (ITP)/immune thrombocytopenia - newly diagnosed (within past 3 months) or initial therapy: medically necessary when (children < 18 years) ONE of significant bleeding symptoms (mucosal/moderate-severe), high risk for bleeding, or rapid platelet increase required (surgery/procedure); OR (adults >= 18 years) platelet count < 30,000/mcL OR platelet count < 50,000/mcL AND significant bleeding symptoms/high risk/rapid increase needed; AND corticosteroid therapy contraindicated with IVIG used alone or combined with corticosteroids; Idiopathic thrombocytopenic purpura (ITP) - chronic/persistent (>= 3 months) or unresponsive to first-line: medically necessary when platelet count < 30,000/mcL OR platelet count < 50,000/mcL AND significant bleeding symptoms/high risk/rapid increase needed; AND (relapse after previous response to IVIG or SCIG OR inadequate response/intolerance/contraindication to corticosteroid or anti-D therapy); Idiopathic thrombocytopenic purpura (ITP) - adults with refractory ITP after splenectomy: medically necessary when EITHER platelet count < 30,000/mcL OR significant bleeding symptoms; Idiopathic thrombocytopenic purpura (ITP) in pregnant women: medically necessary through delivery; B-cell chronic lymphocytic leukemia (CLL) - initial therapy: medically necessary when ALL of (a) IVIG or SCIG prescribed for prophylaxis of bacterial infections; (b) history of recurrent sinopulmonary infections requiring IV antibiotics or hospitalization; (c) pretreatment serum IgG level < 500 mg/dL; B-cell chronic lymphocytic leukemia (CLL) - continued therapy: medically necessary when reduction in frequency of bacterial infections demonstrated; Prophylaxis of bacterial infections in HIV-infected pediatric members - initial therapy: medically necessary when ANY of (a) primary prophylaxis AND pretreatment serum IgG < 400 mg/dL; OR (b) secondary prophylaxis with history of > 2 serious bacterial infections in a 1-year period; OR (c) failed to form antibodies to common antigens (measles, pneumococcal, Haemophilus influenzae type b); OR (d) resides in high-measles area with no antibody response after two doses of live measles, mumps, and rubella virus vaccine; OR (e) exposed to measles, requesting single dose; OR (f) chronic bronchiectasis suboptimally responsive to antimicrobial/pulmonary therapy; Prophylaxis of bacterial infections in HIV-infected pediatric members - continued therapy: medically necessary when reduction in frequency of bacterial infections demonstrated; Bone marrow transplant/hematopoietic stem cell transplant (BMT/HSCT) - initial therapy: medically necessary when prevention of acute graft-versus-host disease, interstitial pneumonia (infectious or idiopathic), septicemia, or infections (CMV, recurrent bacterial) is intended AND EITHER requested within first 100 days post-transplant OR pretreatment serum IgG < 400 mg/dL; Bone marrow transplant/hematopoietic stem cell transplant (BMT/HSCT) - continued therapy: medically necessary when reduction in frequency of bacterial infections demonstrated; Multifocal motor neuropathy (MMN) - initial therapy: medically necessary when ALL of (a) progressive, multifocal, asymmetrical weakness without objective sensory loss in 2 or more nerves for at least 1 month; (b) diagnosis confirmed by electrodiagnostic studies; Multifocal motor neuropathy (MMN) - continued therapy: medically necessary when significant improvement in disability and maintenance since initiation; Guillain-Barre syndrome (GBS) - up to 1 month total treatment: medically necessary when ALL of (a) severe disease with significant weakness (inability to stand/walk without aid, respiratory weakness); (b) onset of neurologic symptoms < 4 weeks from anticipated therapy start; Lambert-Eaton myasthenic syndrome (LEMS) - initial therapy: medically necessary when ALL of (a) diagnosis confirmed by EITHER neurophysiology studies (EMG) OR positive anti-P/Q type voltage-gated calcium channel antibody test; (b) anticholinesterases (e.g., pyridostigmine) and amifampridine (e.g., 3,4-diaminopyridine phosphate, Firdapse) tried but unsuccessful or not tolerated; (c) weakness is severe OR difficulty with venous access for plasmapheresis; Lambert-Eaton myasthenic syndrome (LEMS) - continued therapy: medically necessary when member responding to therapy (stability/improvement relative to natural disease course); Kawasaki syndrome: medically necessary for pediatric members with Kawasaki syndrome; Fetal/neonatal alloimmune thrombocytopenia (F/NAIT): medically necessary for treatment of F/NAIT; Parvovirus B19-induced pure red cell aplasia (PRCA): medically necessary for severe, refractory anemia with bone marrow suppression and parvovirus B19 viremia; Stiff-person syndrome: medically necessary when ALL of (a) diagnosis confirmed by anti-glutamic acid decarboxylase (GAD) antibody testing; (b) inadequate response to first-line treatment (benzodiazepines and/or baclofen); Immune checkpoint inhibitor-related toxicities - 1 month treatment: medically necessary when ALL of (a) moderate or severe adverse event to a PD-1 or PD-L1 inhibitor (e.g., pembrolizumab, nivolumab, atezolizumab, avelumab, durvalumab); (b) offending medication held or discontinued; (c) ONE OR MORE adverse events: myocarditis, bullous dermatitis, Stevens-Johnson syndrome, toxic epidermal necrolysis, pneumonitis, myasthenia gravis, peripheral neuropathy, encephalitis, transverse myelitis, severe inflammatory arthritis, Guillain-Barre syndrome, or steroid-refractory myalgias/myositis; Acquired red cell aplasia: medically necessary for acquired red cell aplasia; Acute disseminated encephalomyelitis: medically necessary for members with insufficient response OR contraindication to intravenous corticosteroid treatment; Autoimmune mucocutaneous blistering disease (pemphigus vulgaris, pemphigus foliaceus, bullous pemphigoid, mucous membrane pemphigoid, epidermolysis bullosa acquisita): medically necessary when ALL of (a) diagnosis proven by biopsy and confirmed by pathology; (b) condition is rapidly progressing, extensive or debilitating; (c) failed or experienced significant complications (e.g., diabetes, steroid-induced osteoporosis) from standard treatment (corticosteroids, immunosuppressive agents); Autoimmune hemolytic anemia: medically necessary for warm-type autoimmune hemolytic anemia in members who do not respond OR have contraindication to corticosteroids or splenectomy; Autoimmune neutropenia: medically necessary where treatment with G-CSF is not appropriate; Birdshot retinochoroidopathy: medically necessary when not responsive to immunosuppressives (e.g., corticosteroids, cyclosporine); BK virus associated nephropathy: medically necessary for BK virus associated nephropathy; Churg-Strauss syndrome: medically necessary for severe, active Churg-Strauss syndrome as adjunctive therapy for members who have experienced failure, intolerance, or are contraindicated to other interventions; Enteroviral meningoencephalitis: medically necessary for severe cases of enteroviral meningoencephalitis; Hemophagocytic lymphohistiocytosis (HLH) or macrophage activation syndrome (MAS): medically necessary for treatment of hypogammaglobulinemia when total IgG is < 400 mg/dL or two standard deviations below the mean for age; Hemolytic disease of the newborn: medically necessary for isoimmune hemolytic disease in neonates; HIV-associated thrombocytopenia - pediatric members: medically necessary when IgG < 400 mg/dL AND ONE of (>= 2 bacterial infections in 1-year despite antibiotic chemoprophylaxis with TMP-SMZ or another active agent; OR received 2 measles vaccine doses and lives in high-prevalence region; OR HIV-associated thrombocytopenia despite antiretroviral therapy; OR chronic bronchiectasis suboptimally responsive to antimicrobial/pulmonary therapy; OR T4 cell count >= 200/mm3); HIV-associated thrombocytopenia - adult members: medically necessary when significant bleeding AND platelet count < 20,000/mcL AND failure of RhIG in Rh-positive persons; Hyperimmunoglobulinemia E syndrome: medically necessary to treat severe eczema; Hypogammaglobulinemia from CAR-T therapy: medically necessary for members with IgG < 400 mg/dL receiving CAR-T therapy (including but not limited to idecabtagene vicleucel [Abecma], tisagenlecleucel [Kymriah], or axicabtagene ciloleucel [Yescarta]); Multiple myeloma: medically necessary for members with recurrent, serious infections despite the use of prophylactic antibiotics; Neonatal hemochromatosis: medically necessary for prophylaxis in pregnant members with a history of pregnancy ending in documented neonatal hemochromatosis; Opsoclonus-myoclonus: medically necessary for EITHER paraneoplastic opsoclonus-myoclonus-ataxia associated with neuroblastoma; OR refractory opsoclonus-myoclonus as last-resort treatment; Pediatric acute-onset neuropsychiatric syndrome (PANS)/PANDAS - initial therapy: medically necessary when ALL of (a) child meets PANS Research Consortium Diagnostic Criteria with abrupt dramatic onset (within less than one month) of OCD or severely restricted food intake; (b) concurrent additional neuropsychiatric symptoms with similarly severe and acute onset from AT LEAST TWO of seven categories (anxiety; emotional lability/depression; irritability/aggression/severely oppositional behaviors; behavioral developmental regression; deterioration in school performance; sensory or motor abnormalities; somatic signs such as sleep disturbances/enuresis/urinary frequency); (c) onset of symptoms occurs between 3 years of age and puberty; (d) documentation that other causes of symptoms have been ruled out; (e) child tried and failed treatment with systemic corticosteroids; (f) documented objective baseline symptom assessment submitted (CY-BOCS, CGIS, PANS Scale); Pediatric acute-onset neuropsychiatric syndrome (PANS)/PANDAS - continued therapy: medically necessary when documentation of objective clinical response submitted (CY-BOCS, CGIS, PANS Scale); Post-transfusion purpura: medically necessary for post-transfusion purpura; Rasmussen encephalitis: medically necessary for members whose symptoms do not improve with anti-epileptic drugs and corticosteroids; Renal transplantation: medically necessary for member undergoing renal transplantation from a live donor with ABO incompatibility or positive cross match; Retinocochleocerebral vasculopathy, central nervous system-predominant (Susac syndrome): medically necessary when used as an adjunctive therapy to corticosteroid and other treatment options; Secondary immunosuppression associated with major surgery, hematological malignancy, extensive burns, or collagen-vascular disease: medically necessary to prevent or modify recurrent bacterial or viral infections in members with secondary immunosuppression (IgG < 400 mg/dL); Solid organ transplantation: medically necessary for allosensitized members; Toxic epidermal necrolysis and Stevens-Johnson syndrome: medically necessary for severe cases; Toxic shock syndrome: medically necessary when the infection is refractory to several hours of aggressive therapy, an undrainable focus is present, or the member has persistent oliguria with pulmonary edema; Systemic lupus erythematosus (SLE): medically necessary for severe, active SLE in members who have experienced inadequate response, intolerance, or have a contraindication to first- and second-line therapies (e.g., hydroxychloroquine, glucocorticoids, anifrolumab, rituximab); Measles (rubeola) prophylaxis: medically necessary for postexposure prophylaxis to prevent or modify symptoms in susceptible members exposed to the disease less than 6 days previously; Tetanus treatment and prophylaxis: medically necessary as an alternative when tetanus immune globulin (TIG) is unavailable; Varicella prophylaxis: medically necessary for postexposure prophylaxis of varicella in susceptible individuals when varicella-zoster immune globulin (VZIG) is unavailable; Toxic necrotizing fasciitis due to Group A Streptococcus: medically necessary for members with fasciitis due to invasive streptococcal infection; Continuation of IVIG or SCIG therapy (general rule): medically necessary when EITHER (a) for conditions with specific continuation criteria above, the member meets the applicable continuation criteria; OR (b) for all other conditions, the member continues to meet the initial medical necessity criteria. Applies to 17 codes: 90283, 90284, J1459, J1551, J1554, J1555, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, J1575, J1576, J1599.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Prior authorization status is code-specific; this CPB is not an exact authorization source for every covered code. Check the Aetna precertification list or PA lookup for the exact code and plan context. Documentation: For continuation of primary immunodeficiency therapy, EITHER IgG trough levels must be monitored at least yearly and maintained at or above the lower range of normal for age (when applicable for indication), OR the prescriber will re-evaluate the dose of IVIG or SCIG and consider a dose adjustment (when appropriate); For ITP indications based upon high risk of bleeding, the member's risk factor(s) for bleeding (see Appendix) or reason requiring a rapid increase in platelets must be provided; For PANS/PANDAS initial therapy: documented objective assessment of baseline symptoms must be submitted (e.g., Children's Yale-Brown Obsessive-Compulsive Scale [CY-BOCS], CGIS, PANS Scale); For PANS/PANDAS continued therapy: documentation of objective clinical response to therapy must be submitted (e.g., CY-BOCS, CGIS, PANS Scale); For PANS/PANDAS: documentation that other causes of symptoms have been ruled out; Diagnosis confirmation by genetic/molecular testing where applicable (e.g., SCID, Wiskott-Aldrich, DiGeorge, ataxia-telangiectasia, other combined immunodeficiency); Diagnosis confirmation by electrodiagnostic studies (CIDP, MMN) or neurophysiology/EMG or anti-P/Q VGCC antibody testing (LEMS); Biopsy with pathology confirmation for autoimmune mucocutaneous blistering disease; Anti-GAD antibody testing for stiff-person syndrome.
Trap
Policy exclusions and limitations: Aetna considers IVIG/SCIG experimental, investigational, or unproven for indications OTHER THAN those listed as covered above - a condition that is covered above remains covered even if it (or its ICD category) appears below (not an all-inclusive list): Aetna considers all other indications (beyond those listed as medically necessary) experimental, investigational, or unproven; Magnesium infusion as a pre-medication for IVIG infusion - experimental, investigational, or unproven; Clostridium difficile enterocolitis - not covered (experimental/investigational/unproven); Tuberculosis of lung - not covered; Diphtheritic myocarditis - not covered; Meningococcal myocarditis - not covered; Syphilitic heart involvement - not covered; Lyme disease - not covered; Hand-foot-mouth disease - not covered; Viral myocarditis - not covered; Toxoplasma myocarditis - not covered; Unspecified parasitic and infectious disease - not covered; Gastric enterovirus - not covered; Rituximab-associated chronic CNS enterovirus infection - not covered; Malignant neoplasm (except hematologic) - not covered; Malignant carcinoid tumor - not covered; Follicular lymphoma (other than secondary immunosuppression with IgG < 400 mg/dL associated with this hematological malignancy, which is covered) - not covered; Burkitt lymphoma (other than secondary immunosuppression with IgG < 400 mg/dL associated with this hematological malignancy, which is covered) - not covered; Waldenstrom macroglobulinemia (other than secondary immunosuppression with IgG < 400 mg/dL associated with this hematological malignancy, which is covered) - not covered; Plasmacytoma (other than secondary immunosuppression with IgG < 400 mg/dL associated with this hematological malignancy, which is covered) - not covered; Acute lymphoblastic leukemia (other than secondary immunosuppression with IgG < 400 mg/dL associated with this hematological malignancy, which is covered) - not covered; Acute myeloid leukemia (other than secondary immunosuppression with IgG < 400 mg/dL associated with this hematological malignancy, which is covered) - not covered; Chronic myeloid leukemia (other than secondary immunosuppression with IgG < 400 mg/dL associated with this hematological malignancy, which is covered) - not covered; Multifocal and multisystemic Langerhans-cell histiocytosis - not covered; Monoclonal gammopathy - not covered; Neoplasms of uncertain behavior of lymphoid tissue - not covered; Hemolytic-uremic syndrome - not covered; Aplastic anemia - not covered; Acquired von Willebrand disease - not covered; Hereditary deficiency of other clotting factors - not covered; Allergic purpura (Henoch-Schonlein) - not covered; Evans syndrome - not covered; Neutropenia (other than autoimmune neutropenia where treatment with G-CSF is not appropriate, which is covered) - not covered; Disease of blood and blood-forming organs unspecified - not covered; Defects in the complement system - not covered; Large granular lymphocytic mediated immune cytopenia - not covered; Sarcoidosis - not covered; Cryoglobulinemia - not covered; Immune reconstitution syndrome - not covered; Diabetes mellitus - not covered; Other sphingolipidosis - not covered; Krabbe disease - not covered; Metachromatic leukodystrophy - not covered; Mucopolysaccharidosis type II - not covered; Lesch-Nyhan syndrome - not covered; Other disorders of purine and pyrimidine metabolism - not covered; Cystic fibrosis - not covered; Alpha-1-antitrypsin deficiency - not covered; Other disorders of plasma-protein metabolism - not covered; Major depressive disorder - not covered; Obsessive-compulsive disorder (other than abrupt-onset OCD as part of pediatric acute-onset neuropsychiatric syndrome [PANS/PANDAS] meeting the listed criteria, which is covered) - not covered; Autistic disorder - not covered; Attention-deficit hyperactivity disorders - not covered; Tic disorder - not covered; Meningitis (infection in neonates) - not covered; Benign recurrent meningitis (Mollaret) - not covered; Encephalitis, myelitis, and encephalomyelitis (other than immune-checkpoint-inhibitor-associated encephalitis/transverse myelitis, and acute disseminated encephalomyelitis with insufficient response or contraindication to IV corticosteroids, which are covered) - not covered; Toxic encephalopathy - not covered; Limbic encephalitis - not covered; Huntington's disease - not covered; Amyotrophic lateral sclerosis - not covered; Parkinson's disease and secondary parkinsonism - not covered; Autoimmune dystonia - not covered; Alzheimer's disease - not covered; Multiple sclerosis - not covered; Neuromyelitis optica (Devic's syndrome) - not covered; Epilepsy and recurrent seizures - not covered; Narcolepsy and cataplexy - not covered; Disorders of multiple cranial nerves - not covered; Neuralgic amyotrophy (Parsonage-Aldren-Turner syndrome) - not covered; Hereditary motor and sensory neuropathy (Charcot-Marie-Tooth) - not covered; Idiopathic progressive neuropathy - not covered; Anti-myelin-associated glycoprotein (anti-MAG) neuropathy - not covered; Idiopathic autonomic neuropathy - not covered; Hereditary and idiopathic neuropathy unspecified - not covered; Drug-induced polyneuropathy (bortezomib-induced) - not covered; Polyneuropathy in diseases classified elsewhere - not covered; Myasthenia gravis without acute exacerbation (including ocular) (other than refractory myasthenia gravis after failure of 2 or more standard therapies, and short-term therapy for worsening weakness, acute exacerbation, or pre-operative management, which are covered) - not covered; Isaacs syndrome - not covered; Other specified myotonic disorders (neuromyotonia) - not covered; Critical illness myopathy (necrotizing myopathy) - not covered; Other idiopathic peripheral autonomic neuropathy - not covered; Disorder of the autonomic nervous system unspecified - not covered; Complex regional pain syndrome I (reflex sympathetic dystrophy) - not covered; Mitochondrial encephalopathy - not covered; Autoimmune encephalopathy - not covered; Vasculitic polyneuropathy - not covered; Orbital myositis - not covered; Scleritis - not covered; Iridocyclitis - not covered; Optic neuritis - not covered; Rheumatic fever without heart involvement - not covered; Rheumatic fever with heart involvement - not covered; Rheumatic chorea without heart involvement (Sydenham's chorea) - not covered; Myocarditis in diseases classified elsewhere - not covered; Other primary cardiomyopathies - not covered; Degos disease - not covered; Clarkson disease (systemic capillary leak syndrome) - not covered; Rheumatoid arthritis and other inflammatory polyarthropathies - not covered; Polyarteritis nodosa - not covered; Goodpasture's syndrome - not covered; Thrombotic microangiopathy - not covered; Wegener's granulomatosis - not covered; Other specified necrotizing vasculopathies - not covered; Systemic sclerosis (scleroderma) - not covered; Sicca syndrome (Sjogren's syndrome) - not covered; Anti-synthetase syndrome - not covered; Other myositis and fibromyalgia (other than steroid-refractory myositis as an immune checkpoint inhibitor [PD-1 or PD-L1] related toxicity meeting the listed criteria, which is covered) - not covered; Myalgia (other than steroid-refractory myalgias as an immune checkpoint inhibitor [PD-1 or PD-L1] related toxicity meeting the listed criteria, which is covered) - not covered; Relapsing polychondritis - not covered; Nephritis and nephrotic syndrome - not covered; Unspecified nephritic syndrome with diffuse membranous glomerulonephritis - not covered; Unspecified nephritic syndrome with diffuse mesangiocapillary glomerulonephritis - not covered; Acute kidney failure - not covered; Acute vaginitis (neutrophilic necrotizing vulvovaginitis) - not covered; Female infertility - not covered; Maternal care for rhesus isoimmunization - not covered; Maternal care for other isoimmunization - not covered; Pneumonia (not related to RSV) - not covered; Chronic sinusitis - not covered; Asthma - not covered; Other interstitial pulmonary diseases with fibrosis - not covered; Idiopathic pulmonary fibrosis - not covered; Respiratory bronchiolitis interstitial lung disease - not covered; Other specified interstitial pulmonary diseases - not covered; Diseases of stomach and duodenum - not covered; Noninfective enteritis and colitis - not covered; Vascular disorders of intestine - not covered; Other diseases of intestines - not covered; Idiopathic chronic serositis - not covered; Stomatitis and related lesions (oral ulcers) - not covered; Other diseases of lip and oral mucosa (oral ulcers) - not covered; Bullous disorders (other than autoimmune mucocutaneous blistering disease - e.g., pemphigus vulgaris, pemphigus foliaceus, bullous pemphigoid, mucous membrane pemphigoid, epidermolysis bullosa acquisita - meeting the listed criteria, which is covered) - not covered; Dermatitis unspecified (eczema NOS) (other than severe eczema in hyperimmunoglobulinemia E syndrome, which is covered) - not covered; Lichen planus (oral) - not covered; Other urticaria - not covered; Solar urticaria - not covered; Pyoderma gangrenosum - not covered; Calcinosis cutis - not covered; Livedoid vasculitis - not covered; Urticarial vasculitis - not covered; Febrile neutrophilic dermatosis (Sweet syndrome) - not covered; Reiter's disease - not covered; Tachycardia unspecified (orthostatic tachycardia syndrome) - not covered; Hemoptysis (diffuse alveolar hemorrhage) - not covered; Rash and other nonspecific skin eruption (implantation rash) - not covered; Fasciculation (cramp-fasciculation syndrome) - not covered; Chronic fatigue syndrome - not covered; Unspecified convulsions - not covered; Shock not elsewhere classified - not covered; Other and unspecified abnormal immunological findings in serum - not covered; Spinal cord injury - not covered; Adverse effect of antineoplastic and immunosuppressive drugs (other than moderate or severe immune checkpoint inhibitor [PD-1 or PD-L1] related toxicities meeting the listed criteria, which are covered) - not covered; Angioneurotic edema - not covered; COVID-19 - not covered; Personal history of diseases of the female genital tract - not covered; Personal history of complications of pregnancy, childbirth and puerperium - not covered. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source: Aetna CPB 0206 — Intravenous Immunoglobulins (IVIG)

Coverage criteria

  • Primary immunodeficiency - SCID or congenital agammaglobulinemia: medically necessary when ONE of (a) diagnosis confirmed by genetic/molecular testing; OR (b) pretreatment IgG level < 200 mg/dL; OR (c) absence or very low T cells (CD3 < 300/microliter) or the presence of maternal T cells in the circulation (SCID only)
  • Primary immunodeficiency - Wiskott-Aldrich syndrome, DiGeorge syndrome, or ataxia-telangiectasia: medically necessary when ALL of (a) diagnosis confirmed by genetic/molecular testing (if applicable); (b) history of recurrent bacterial infections (e.g., pneumonia, otitis media, sinusitis, sepsis, gastrointestinal); (c) impaired antibody response to pneumococcal polysaccharide vaccine
  • Primary immunodeficiency - Common variable immunodeficiency (CVID): medically necessary when ALL of (a) age >= 2 years; (b) other causes of immune deficiency excluded; (c) pretreatment IgG level < 500 mg/dL or >= 2 SD below the mean for age; (d) history of recurrent bacterial infections; (e) impaired antibody response to pneumococcal polysaccharide vaccine
  • Primary immunodeficiency - Hypogammaglobulinemia (unspecified), IgG subclass deficiency, selective IgA/IgM deficiency, or specific antibody deficiency: medically necessary when ALL of (a) history of recurrent bacterial infections; (b) impaired antibody response to pneumococcal polysaccharide vaccine; AND (c) ANY ONE of the pretreatment lab findings: hypogammaglobulinemia IgG < 500 mg/dL or >= 2 SD below the mean for age; OR selective IgA deficiency IgA < 7 mg/dL with normal IgG/IgM; OR selective IgM deficiency IgM < 30 mg/dL with normal IgG/IgA; OR IgG subclass deficiency IgG1/2/3 >= 2 SD below mean for age on >= 2 occasions, with normal IgG (total) and IgM levels and normal/low IgA levels; OR specific antibody deficiency with normal IgG/IgA/IgM
  • Primary immunodeficiency - Other predominant antibody deficiency disorders: medically necessary when ALL of (a) history of recurrent bacterial infections; (b) impaired antibody response to pneumococcal polysaccharide vaccine; (c) pretreatment hypogammaglobulinemia IgG < 500 mg/dL or >= 2 SD below the mean for age
  • Primary immunodeficiency - Other combined immunodeficiency: medically necessary when ALL of (a) diagnosis confirmed by genetic/molecular testing (if applicable); (b) history of recurrent bacterial infections; (c) impaired antibody response to pneumococcal polysaccharide vaccine
  • Primary immunodeficiency - Continuation of therapy: medically necessary when (a) reduction in frequency of bacterial infections documented; AND EITHER (b) IgG trough levels monitored at least yearly and maintained at or above the lower range of normal for age (when applicable for indication); OR (c) prescriber re-evaluates dose and considers a dose adjustment (when appropriate)
  • Myasthenia gravis - short-term therapy (one month): medically necessary for ONE of (a) worsening weakness (diplopia, ptosis, blurred vision, dysarthria, dysphagia, difficulty chewing, impaired respiration, fatigue, limb weakness); OR (b) acute exacerbations (severe swallowing difficulties, respiratory failure); OR (c) pre-operative management (e.g., prior to thymectomy)
  • Myasthenia gravis - chronic/refractory: medically necessary when patient has tried and failed 2 or more standard therapies (e.g., corticosteroids, azathioprine, cyclosporine, mycophenolate mofetil, rituximab)
  • Chronic inflammatory demyelinating polyneuropathy (CIDP) - initial therapy: medically necessary when ALL of (a) disease course is progressive or relapsing/remitting for 2 months or longer; (b) moderate to severe functional disability; (c) diagnosis confirmed by electrodiagnostic studies
  • Chronic inflammatory demyelinating polyneuropathy (CIDP) - continued treatment: medically necessary when ALL of (a) significant improvement in disability and maintenance since initiation; (b) IVIG or SCIG is being used at the lowest effective dose and frequency
  • Dermatomyositis or polymyositis - initial therapy: medically necessary when member has AT LEAST FOUR of (proximal muscle weakness of upper/lower extremity or trunk; elevated serum creatine kinase or aldolase; muscle pain on grasping or spontaneous pain; myogenic changes on EMG; positive anti-synthetase antibodies anti-Jo-1; non-destructive arthritis or arthralgias; systemic inflammatory signs fever > 37C axilla or elevated CRP or ESR > 20 mm/h by the Westergren method; pathological findings compatible with inflammatory myositis (inflammatory infiltration of skeletal muscle / active regeneration may be seen)) AND EITHER standard first-line (corticosteroids) and second-line (immunosuppressants) treatments tried but unsuccessful or not tolerated; OR member unable to receive standard therapies due to contraindication/clinical reason
  • Dermatomyositis or polymyositis - continued therapy: medically necessary when significant improvement in disability and maintenance since initiation
  • Idiopathic thrombocytopenic purpura (ITP)/immune thrombocytopenia - newly diagnosed (within past 3 months) or initial therapy: medically necessary when (children < 18 years) ONE of significant bleeding symptoms (mucosal/moderate-severe), high risk for bleeding, or rapid platelet increase required (surgery/procedure); OR (adults >= 18 years) platelet count < 30,000/mcL OR platelet count < 50,000/mcL AND significant bleeding symptoms/high risk/rapid increase needed; AND corticosteroid therapy contraindicated with IVIG used alone or combined with corticosteroids
  • Idiopathic thrombocytopenic purpura (ITP) - chronic/persistent (>= 3 months) or unresponsive to first-line: medically necessary when platelet count < 30,000/mcL OR platelet count < 50,000/mcL AND significant bleeding symptoms/high risk/rapid increase needed; AND (relapse after previous response to IVIG or SCIG OR inadequate response/intolerance/contraindication to corticosteroid or anti-D therapy)
  • Idiopathic thrombocytopenic purpura (ITP) - adults with refractory ITP after splenectomy: medically necessary when EITHER platelet count < 30,000/mcL OR significant bleeding symptoms
  • Idiopathic thrombocytopenic purpura (ITP) in pregnant women: medically necessary through delivery
  • B-cell chronic lymphocytic leukemia (CLL) - initial therapy: medically necessary when ALL of (a) IVIG or SCIG prescribed for prophylaxis of bacterial infections; (b) history of recurrent sinopulmonary infections requiring IV antibiotics or hospitalization; (c) pretreatment serum IgG level < 500 mg/dL
  • B-cell chronic lymphocytic leukemia (CLL) - continued therapy: medically necessary when reduction in frequency of bacterial infections demonstrated
  • Prophylaxis of bacterial infections in HIV-infected pediatric members - initial therapy: medically necessary when ANY of (a) primary prophylaxis AND pretreatment serum IgG < 400 mg/dL; OR (b) secondary prophylaxis with history of > 2 serious bacterial infections in a 1-year period; OR (c) failed to form antibodies to common antigens (measles, pneumococcal, Haemophilus influenzae type b); OR (d) resides in high-measles area with no antibody response after two doses of live measles, mumps, and rubella virus vaccine; OR (e) exposed to measles, requesting single dose; OR (f) chronic bronchiectasis suboptimally responsive to antimicrobial/pulmonary therapy
  • Prophylaxis of bacterial infections in HIV-infected pediatric members - continued therapy: medically necessary when reduction in frequency of bacterial infections demonstrated
  • Bone marrow transplant/hematopoietic stem cell transplant (BMT/HSCT) - initial therapy: medically necessary when prevention of acute graft-versus-host disease, interstitial pneumonia (infectious or idiopathic), septicemia, or infections (CMV, recurrent bacterial) is intended AND EITHER requested within first 100 days post-transplant OR pretreatment serum IgG < 400 mg/dL
  • Bone marrow transplant/hematopoietic stem cell transplant (BMT/HSCT) - continued therapy: medically necessary when reduction in frequency of bacterial infections demonstrated
  • Multifocal motor neuropathy (MMN) - initial therapy: medically necessary when ALL of (a) progressive, multifocal, asymmetrical weakness without objective sensory loss in 2 or more nerves for at least 1 month; (b) diagnosis confirmed by electrodiagnostic studies
  • Multifocal motor neuropathy (MMN) - continued therapy: medically necessary when significant improvement in disability and maintenance since initiation
  • Guillain-Barre syndrome (GBS) - up to 1 month total treatment: medically necessary when ALL of (a) severe disease with significant weakness (inability to stand/walk without aid, respiratory weakness); (b) onset of neurologic symptoms < 4 weeks from anticipated therapy start
  • Lambert-Eaton myasthenic syndrome (LEMS) - initial therapy: medically necessary when ALL of (a) diagnosis confirmed by EITHER neurophysiology studies (EMG) OR positive anti-P/Q type voltage-gated calcium channel antibody test; (b) anticholinesterases (e.g., pyridostigmine) and amifampridine (e.g., 3,4-diaminopyridine phosphate, Firdapse) tried but unsuccessful or not tolerated; (c) weakness is severe OR difficulty with venous access for plasmapheresis
  • Lambert-Eaton myasthenic syndrome (LEMS) - continued therapy: medically necessary when member responding to therapy (stability/improvement relative to natural disease course)
  • Kawasaki syndrome: medically necessary for pediatric members with Kawasaki syndrome
  • Fetal/neonatal alloimmune thrombocytopenia (F/NAIT): medically necessary for treatment of F/NAIT
  • Parvovirus B19-induced pure red cell aplasia (PRCA): medically necessary for severe, refractory anemia with bone marrow suppression and parvovirus B19 viremia
  • Stiff-person syndrome: medically necessary when ALL of (a) diagnosis confirmed by anti-glutamic acid decarboxylase (GAD) antibody testing; (b) inadequate response to first-line treatment (benzodiazepines and/or baclofen)
  • Immune checkpoint inhibitor-related toxicities - 1 month treatment: medically necessary when ALL of (a) moderate or severe adverse event to a PD-1 or PD-L1 inhibitor (e.g., pembrolizumab, nivolumab, atezolizumab, avelumab, durvalumab); (b) offending medication held or discontinued; (c) ONE OR MORE adverse events: myocarditis, bullous dermatitis, Stevens-Johnson syndrome, toxic epidermal necrolysis, pneumonitis, myasthenia gravis, peripheral neuropathy, encephalitis, transverse myelitis, severe inflammatory arthritis, Guillain-Barre syndrome, or steroid-refractory myalgias/myositis
  • Acquired red cell aplasia: medically necessary for acquired red cell aplasia
  • Acute disseminated encephalomyelitis: medically necessary for members with insufficient response OR contraindication to intravenous corticosteroid treatment
  • Autoimmune mucocutaneous blistering disease (pemphigus vulgaris, pemphigus foliaceus, bullous pemphigoid, mucous membrane pemphigoid, epidermolysis bullosa acquisita): medically necessary when ALL of (a) diagnosis proven by biopsy and confirmed by pathology; (b) condition is rapidly progressing, extensive or debilitating; (c) failed or experienced significant complications (e.g., diabetes, steroid-induced osteoporosis) from standard treatment (corticosteroids, immunosuppressive agents)
  • Autoimmune hemolytic anemia: medically necessary for warm-type autoimmune hemolytic anemia in members who do not respond OR have contraindication to corticosteroids or splenectomy
  • Autoimmune neutropenia: medically necessary where treatment with G-CSF is not appropriate
  • Birdshot retinochoroidopathy: medically necessary when not responsive to immunosuppressives (e.g., corticosteroids, cyclosporine)
  • BK virus associated nephropathy: medically necessary for BK virus associated nephropathy
  • Churg-Strauss syndrome: medically necessary for severe, active Churg-Strauss syndrome as adjunctive therapy for members who have experienced failure, intolerance, or are contraindicated to other interventions
  • Enteroviral meningoencephalitis: medically necessary for severe cases of enteroviral meningoencephalitis
  • Hemophagocytic lymphohistiocytosis (HLH) or macrophage activation syndrome (MAS): medically necessary for treatment of hypogammaglobulinemia when total IgG is < 400 mg/dL or two standard deviations below the mean for age
  • Hemolytic disease of the newborn: medically necessary for isoimmune hemolytic disease in neonates
  • HIV-associated thrombocytopenia - pediatric members: medically necessary when IgG < 400 mg/dL AND ONE of (>= 2 bacterial infections in 1-year despite antibiotic chemoprophylaxis with TMP-SMZ or another active agent; OR received 2 measles vaccine doses and lives in high-prevalence region; OR HIV-associated thrombocytopenia despite antiretroviral therapy; OR chronic bronchiectasis suboptimally responsive to antimicrobial/pulmonary therapy; OR T4 cell count >= 200/mm3)
  • HIV-associated thrombocytopenia - adult members: medically necessary when significant bleeding AND platelet count < 20,000/mcL AND failure of RhIG in Rh-positive persons
  • Hyperimmunoglobulinemia E syndrome: medically necessary to treat severe eczema
  • Hypogammaglobulinemia from CAR-T therapy: medically necessary for members with IgG < 400 mg/dL receiving CAR-T therapy (including but not limited to idecabtagene vicleucel [Abecma], tisagenlecleucel [Kymriah], or axicabtagene ciloleucel [Yescarta])
  • Multiple myeloma: medically necessary for members with recurrent, serious infections despite the use of prophylactic antibiotics
  • Neonatal hemochromatosis: medically necessary for prophylaxis in pregnant members with a history of pregnancy ending in documented neonatal hemochromatosis
  • Opsoclonus-myoclonus: medically necessary for EITHER paraneoplastic opsoclonus-myoclonus-ataxia associated with neuroblastoma; OR refractory opsoclonus-myoclonus as last-resort treatment
  • Pediatric acute-onset neuropsychiatric syndrome (PANS)/PANDAS - initial therapy: medically necessary when ALL of (a) child meets PANS Research Consortium Diagnostic Criteria with abrupt dramatic onset (within less than one month) of OCD or severely restricted food intake; (b) concurrent additional neuropsychiatric symptoms with similarly severe and acute onset from AT LEAST TWO of seven categories (anxiety; emotional lability/depression; irritability/aggression/severely oppositional behaviors; behavioral developmental regression; deterioration in school performance; sensory or motor abnormalities; somatic signs such as sleep disturbances/enuresis/urinary frequency); (c) onset of symptoms occurs between 3 years of age and puberty; (d) documentation that other causes of symptoms have been ruled out; (e) child tried and failed treatment with systemic corticosteroids; (f) documented objective baseline symptom assessment submitted (CY-BOCS, CGIS, PANS Scale)
  • Pediatric acute-onset neuropsychiatric syndrome (PANS)/PANDAS - continued therapy: medically necessary when documentation of objective clinical response submitted (CY-BOCS, CGIS, PANS Scale)
  • Post-transfusion purpura: medically necessary for post-transfusion purpura
  • Rasmussen encephalitis: medically necessary for members whose symptoms do not improve with anti-epileptic drugs and corticosteroids
  • Renal transplantation: medically necessary for member undergoing renal transplantation from a live donor with ABO incompatibility or positive cross match
  • Retinocochleocerebral vasculopathy, central nervous system-predominant (Susac syndrome): medically necessary when used as an adjunctive therapy to corticosteroid and other treatment options
  • Secondary immunosuppression associated with major surgery, hematological malignancy, extensive burns, or collagen-vascular disease: medically necessary to prevent or modify recurrent bacterial or viral infections in members with secondary immunosuppression (IgG < 400 mg/dL)
  • Solid organ transplantation: medically necessary for allosensitized members
  • Toxic epidermal necrolysis and Stevens-Johnson syndrome: medically necessary for severe cases
  • Toxic shock syndrome: medically necessary when the infection is refractory to several hours of aggressive therapy, an undrainable focus is present, or the member has persistent oliguria with pulmonary edema
  • Systemic lupus erythematosus (SLE): medically necessary for severe, active SLE in members who have experienced inadequate response, intolerance, or have a contraindication to first- and second-line therapies (e.g., hydroxychloroquine, glucocorticoids, anifrolumab, rituximab)
  • Measles (rubeola) prophylaxis: medically necessary for postexposure prophylaxis to prevent or modify symptoms in susceptible members exposed to the disease less than 6 days previously
  • Tetanus treatment and prophylaxis: medically necessary as an alternative when tetanus immune globulin (TIG) is unavailable
  • Varicella prophylaxis: medically necessary for postexposure prophylaxis of varicella in susceptible individuals when varicella-zoster immune globulin (VZIG) is unavailable
  • Toxic necrotizing fasciitis due to Group A Streptococcus: medically necessary for members with fasciitis due to invasive streptococcal infection
  • Continuation of IVIG or SCIG therapy (general rule): medically necessary when EITHER (a) for conditions with specific continuation criteria above, the member meets the applicable continuation criteria; OR (b) for all other conditions, the member continues to meet the initial medical necessity criteria

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Documentation required

  • For continuation of primary immunodeficiency therapy, EITHER IgG trough levels must be monitored at least yearly and maintained at or above the lower range of normal for age (when applicable for indication), OR the prescriber will re-evaluate the dose of IVIG or SCIG and consider a dose adjustment (when appropriate)
  • For ITP indications based upon high risk of bleeding, the member's risk factor(s) for bleeding (see Appendix) or reason requiring a rapid increase in platelets must be provided
  • For PANS/PANDAS initial therapy: documented objective assessment of baseline symptoms must be submitted (e.g., Children's Yale-Brown Obsessive-Compulsive Scale [CY-BOCS], CGIS, PANS Scale)
  • For PANS/PANDAS continued therapy: documentation of objective clinical response to therapy must be submitted (e.g., CY-BOCS, CGIS, PANS Scale)
  • For PANS/PANDAS: documentation that other causes of symptoms have been ruled out
  • Diagnosis confirmation by genetic/molecular testing where applicable (e.g., SCID, Wiskott-Aldrich, DiGeorge, ataxia-telangiectasia, other combined immunodeficiency)
  • Diagnosis confirmation by electrodiagnostic studies (CIDP, MMN) or neurophysiology/EMG or anti-P/Q VGCC antibody testing (LEMS)
  • Biopsy with pathology confirmation for autoimmune mucocutaneous blistering disease
  • Anti-GAD antibody testing for stiff-person syndrome

Frequently asked questions

When does Aetna cover Intravenous Immunoglobulins (IVIG) (CPT 90283), and what gets it denied?
Aetna covers IVIG (and subcutaneous immunoglobulin) only for a defined list of conditions - primarily primary immunodeficiencies with documented low IgG and impaired vaccine response, plus specific neurologic, hematologic, autoimmune, transplant, and infectious indications - and most require meeting detailed lab thresholds and/or prior failure of standard therapy. Precertification is required for all IVIG/SCIG, and any indication not explicitly listed (including conditions like Alzheimer's, autism, multiple sclerosis, chronic fatigue syndrome, and COVID-19) is considered experimental, investigational, or unproven. Coverage criteria include: Primary immunodeficiency - SCID or congenital agammaglobulinemia: medically necessary when ONE of (a) diagnosis confirmed by genetic/molecular testing; OR (b) pretreatment IgG level < 200 mg/dL; OR (c) absence or very low T cells (CD3 < 300/microliter) or the presence of maternal T cells in the circulation (SCID only); Primary immunodeficiency - Wiskott-Aldrich syndrome, DiGeorge syndrome, or ataxia-telangiectasia: medically necessary when ALL of (a) diagnosis confirmed by genetic/molecular testing (if applicable); (b) history of recurrent bacterial infections (e.g., pneumonia, otitis media, sinusitis, sepsis, gastrointestinal); (c) impaired antibody response to pneumococcal polysaccharide vaccine; Primary immunodeficiency - Common variable immunodeficiency (CVID): medically necessary when ALL of (a) age >= 2 years; (b) other causes of immune deficiency excluded; (c) pretreatment IgG level < 500 mg/dL or >= 2 SD below the mean for age; (d) history of recurrent bacterial infections; (e) impaired antibody response to pneumococcal polysaccharide vaccine; Primary immunodeficiency - Hypogammaglobulinemia (unspecified), IgG subclass deficiency, selective IgA/IgM deficiency, or specific antibody deficiency: medically necessary when ALL of (a) history of recurrent bacterial infections; (b) impaired antibody response to pneumococcal polysaccharide vaccine; AND (c) ANY ONE of the pretreatment lab findings: hypogammaglobulinemia IgG < 500 mg/dL or >= 2 SD below the mean for age; OR selective IgA deficiency IgA < 7 mg/dL with normal IgG/IgM; OR selective IgM deficiency IgM < 30 mg/dL with normal IgG/IgA; OR IgG subclass deficiency IgG1/2/3 >= 2 SD below mean for age on >= 2 occasions, with normal IgG (total) and IgM levels and normal/low IgA levels; OR specific antibody deficiency with normal IgG/IgA/IgM; Primary immunodeficiency - Other predominant antibody deficiency disorders: medically necessary when ALL of (a) history of recurrent bacterial infections; (b) impaired antibody response to pneumococcal polysaccharide vaccine; (c) pretreatment hypogammaglobulinemia IgG < 500 mg/dL or >= 2 SD below the mean for age; Primary immunodeficiency - Other combined immunodeficiency: medically necessary when ALL of (a) diagnosis confirmed by genetic/molecular testing (if applicable); (b) history of recurrent bacterial infections; (c) impaired antibody response to pneumococcal polysaccharide vaccine; Primary immunodeficiency - Continuation of therapy: medically necessary when (a) reduction in frequency of bacterial infections documented; AND EITHER (b) IgG trough levels monitored at least yearly and maintained at or above the lower range of normal for age (when applicable for indication); OR (c) prescriber re-evaluates dose and considers a dose adjustment (when appropriate); Myasthenia gravis - short-term therapy (one month): medically necessary for ONE of (a) worsening weakness (diplopia, ptosis, blurred vision, dysarthria, dysphagia, difficulty chewing, impaired respiration, fatigue, limb weakness); OR (b) acute exacerbations (severe swallowing difficulties, respiratory failure); OR (c) pre-operative management (e.g., prior to thymectomy); Myasthenia gravis - chronic/refractory: medically necessary when patient has tried and failed 2 or more standard therapies (e.g., corticosteroids, azathioprine, cyclosporine, mycophenolate mofetil, rituximab); Chronic inflammatory demyelinating polyneuropathy (CIDP) - initial therapy: medically necessary when ALL of (a) disease course is progressive or relapsing/remitting for 2 months or longer; (b) moderate to severe functional disability; (c) diagnosis confirmed by electrodiagnostic studies; Chronic inflammatory demyelinating polyneuropathy (CIDP) - continued treatment: medically necessary when ALL of (a) significant improvement in disability and maintenance since initiation; (b) IVIG or SCIG is being used at the lowest effective dose and frequency; Dermatomyositis or polymyositis - initial therapy: medically necessary when member has AT LEAST FOUR of (proximal muscle weakness of upper/lower extremity or trunk; elevated serum creatine kinase or aldolase; muscle pain on grasping or spontaneous pain; myogenic changes on EMG; positive anti-synthetase antibodies anti-Jo-1; non-destructive arthritis or arthralgias; systemic inflammatory signs fever > 37C axilla or elevated CRP or ESR > 20 mm/h by the Westergren method; pathological findings compatible with inflammatory myositis (inflammatory infiltration of skeletal muscle / active regeneration may be seen)) AND EITHER standard first-line (corticosteroids) and second-line (immunosuppressants) treatments tried but unsuccessful or not tolerated; OR member unable to receive standard therapies due to contraindication/clinical reason; Dermatomyositis or polymyositis - continued therapy: medically necessary when significant improvement in disability and maintenance since initiation; Idiopathic thrombocytopenic purpura (ITP)/immune thrombocytopenia - newly diagnosed (within past 3 months) or initial therapy: medically necessary when (children < 18 years) ONE of significant bleeding symptoms (mucosal/moderate-severe), high risk for bleeding, or rapid platelet increase required (surgery/procedure); OR (adults >= 18 years) platelet count < 30,000/mcL OR platelet count < 50,000/mcL AND significant bleeding symptoms/high risk/rapid increase needed; AND corticosteroid therapy contraindicated with IVIG used alone or combined with corticosteroids; Idiopathic thrombocytopenic purpura (ITP) - chronic/persistent (>= 3 months) or unresponsive to first-line: medically necessary when platelet count < 30,000/mcL OR platelet count < 50,000/mcL AND significant bleeding symptoms/high risk/rapid increase needed; AND (relapse after previous response to IVIG or SCIG OR inadequate response/intolerance/contraindication to corticosteroid or anti-D therapy); Idiopathic thrombocytopenic purpura (ITP) - adults with refractory ITP after splenectomy: medically necessary when EITHER platelet count < 30,000/mcL OR significant bleeding symptoms; Idiopathic thrombocytopenic purpura (ITP) in pregnant women: medically necessary through delivery; B-cell chronic lymphocytic leukemia (CLL) - initial therapy: medically necessary when ALL of (a) IVIG or SCIG prescribed for prophylaxis of bacterial infections; (b) history of recurrent sinopulmonary infections requiring IV antibiotics or hospitalization; (c) pretreatment serum IgG level < 500 mg/dL; B-cell chronic lymphocytic leukemia (CLL) - continued therapy: medically necessary when reduction in frequency of bacterial infections demonstrated; Prophylaxis of bacterial infections in HIV-infected pediatric members - initial therapy: medically necessary when ANY of (a) primary prophylaxis AND pretreatment serum IgG < 400 mg/dL; OR (b) secondary prophylaxis with history of > 2 serious bacterial infections in a 1-year period; OR (c) failed to form antibodies to common antigens (measles, pneumococcal, Haemophilus influenzae type b); OR (d) resides in high-measles area with no antibody response after two doses of live measles, mumps, and rubella virus vaccine; OR (e) exposed to measles, requesting single dose; OR (f) chronic bronchiectasis suboptimally responsive to antimicrobial/pulmonary therapy; Prophylaxis of bacterial infections in HIV-infected pediatric members - continued therapy: medically necessary when reduction in frequency of bacterial infections demonstrated; Bone marrow transplant/hematopoietic stem cell transplant (BMT/HSCT) - initial therapy: medically necessary when prevention of acute graft-versus-host disease, interstitial pneumonia (infectious or idiopathic), septicemia, or infections (CMV, recurrent bacterial) is intended AND EITHER requested within first 100 days post-transplant OR pretreatment serum IgG < 400 mg/dL; Bone marrow transplant/hematopoietic stem cell transplant (BMT/HSCT) - continued therapy: medically necessary when reduction in frequency of bacterial infections demonstrated; Multifocal motor neuropathy (MMN) - initial therapy: medically necessary when ALL of (a) progressive, multifocal, asymmetrical weakness without objective sensory loss in 2 or more nerves for at least 1 month; (b) diagnosis confirmed by electrodiagnostic studies; Multifocal motor neuropathy (MMN) - continued therapy: medically necessary when significant improvement in disability and maintenance since initiation; Guillain-Barre syndrome (GBS) - up to 1 month total treatment: medically necessary when ALL of (a) severe disease with significant weakness (inability to stand/walk without aid, respiratory weakness); (b) onset of neurologic symptoms < 4 weeks from anticipated therapy start; Lambert-Eaton myasthenic syndrome (LEMS) - initial therapy: medically necessary when ALL of (a) diagnosis confirmed by EITHER neurophysiology studies (EMG) OR positive anti-P/Q type voltage-gated calcium channel antibody test; (b) anticholinesterases (e.g., pyridostigmine) and amifampridine (e.g., 3,4-diaminopyridine phosphate, Firdapse) tried but unsuccessful or not tolerated; (c) weakness is severe OR difficulty with venous access for plasmapheresis; Lambert-Eaton myasthenic syndrome (LEMS) - continued therapy: medically necessary when member responding to therapy (stability/improvement relative to natural disease course); Kawasaki syndrome: medically necessary for pediatric members with Kawasaki syndrome; Fetal/neonatal alloimmune thrombocytopenia (F/NAIT): medically necessary for treatment of F/NAIT; Parvovirus B19-induced pure red cell aplasia (PRCA): medically necessary for severe, refractory anemia with bone marrow suppression and parvovirus B19 viremia; Stiff-person syndrome: medically necessary when ALL of (a) diagnosis confirmed by anti-glutamic acid decarboxylase (GAD) antibody testing; (b) inadequate response to first-line treatment (benzodiazepines and/or baclofen); Immune checkpoint inhibitor-related toxicities - 1 month treatment: medically necessary when ALL of (a) moderate or severe adverse event to a PD-1 or PD-L1 inhibitor (e.g., pembrolizumab, nivolumab, atezolizumab, avelumab, durvalumab); (b) offending medication held or discontinued; (c) ONE OR MORE adverse events: myocarditis, bullous dermatitis, Stevens-Johnson syndrome, toxic epidermal necrolysis, pneumonitis, myasthenia gravis, peripheral neuropathy, encephalitis, transverse myelitis, severe inflammatory arthritis, Guillain-Barre syndrome, or steroid-refractory myalgias/myositis; Acquired red cell aplasia: medically necessary for acquired red cell aplasia; Acute disseminated encephalomyelitis: medically necessary for members with insufficient response OR contraindication to intravenous corticosteroid treatment; Autoimmune mucocutaneous blistering disease (pemphigus vulgaris, pemphigus foliaceus, bullous pemphigoid, mucous membrane pemphigoid, epidermolysis bullosa acquisita): medically necessary when ALL of (a) diagnosis proven by biopsy and confirmed by pathology; (b) condition is rapidly progressing, extensive or debilitating; (c) failed or experienced significant complications (e.g., diabetes, steroid-induced osteoporosis) from standard treatment (corticosteroids, immunosuppressive agents); Autoimmune hemolytic anemia: medically necessary for warm-type autoimmune hemolytic anemia in members who do not respond OR have contraindication to corticosteroids or splenectomy; Autoimmune neutropenia: medically necessary where treatment with G-CSF is not appropriate; Birdshot retinochoroidopathy: medically necessary when not responsive to immunosuppressives (e.g., corticosteroids, cyclosporine); BK virus associated nephropathy: medically necessary for BK virus associated nephropathy; Churg-Strauss syndrome: medically necessary for severe, active Churg-Strauss syndrome as adjunctive therapy for members who have experienced failure, intolerance, or are contraindicated to other interventions; Enteroviral meningoencephalitis: medically necessary for severe cases of enteroviral meningoencephalitis; Hemophagocytic lymphohistiocytosis (HLH) or macrophage activation syndrome (MAS): medically necessary for treatment of hypogammaglobulinemia when total IgG is < 400 mg/dL or two standard deviations below the mean for age; Hemolytic disease of the newborn: medically necessary for isoimmune hemolytic disease in neonates; HIV-associated thrombocytopenia - pediatric members: medically necessary when IgG < 400 mg/dL AND ONE of (>= 2 bacterial infections in 1-year despite antibiotic chemoprophylaxis with TMP-SMZ or another active agent; OR received 2 measles vaccine doses and lives in high-prevalence region; OR HIV-associated thrombocytopenia despite antiretroviral therapy; OR chronic bronchiectasis suboptimally responsive to antimicrobial/pulmonary therapy; OR T4 cell count >= 200/mm3); HIV-associated thrombocytopenia - adult members: medically necessary when significant bleeding AND platelet count < 20,000/mcL AND failure of RhIG in Rh-positive persons; Hyperimmunoglobulinemia E syndrome: medically necessary to treat severe eczema; Hypogammaglobulinemia from CAR-T therapy: medically necessary for members with IgG < 400 mg/dL receiving CAR-T therapy (including but not limited to idecabtagene vicleucel [Abecma], tisagenlecleucel [Kymriah], or axicabtagene ciloleucel [Yescarta]); Multiple myeloma: medically necessary for members with recurrent, serious infections despite the use of prophylactic antibiotics; Neonatal hemochromatosis: medically necessary for prophylaxis in pregnant members with a history of pregnancy ending in documented neonatal hemochromatosis; Opsoclonus-myoclonus: medically necessary for EITHER paraneoplastic opsoclonus-myoclonus-ataxia associated with neuroblastoma; OR refractory opsoclonus-myoclonus as last-resort treatment; Pediatric acute-onset neuropsychiatric syndrome (PANS)/PANDAS - initial therapy: medically necessary when ALL of (a) child meets PANS Research Consortium Diagnostic Criteria with abrupt dramatic onset (within less than one month) of OCD or severely restricted food intake; (b) concurrent additional neuropsychiatric symptoms with similarly severe and acute onset from AT LEAST TWO of seven categories (anxiety; emotional lability/depression; irritability/aggression/severely oppositional behaviors; behavioral developmental regression; deterioration in school performance; sensory or motor abnormalities; somatic signs such as sleep disturbances/enuresis/urinary frequency); (c) onset of symptoms occurs between 3 years of age and puberty; (d) documentation that other causes of symptoms have been ruled out; (e) child tried and failed treatment with systemic corticosteroids; (f) documented objective baseline symptom assessment submitted (CY-BOCS, CGIS, PANS Scale); Pediatric acute-onset neuropsychiatric syndrome (PANS)/PANDAS - continued therapy: medically necessary when documentation of objective clinical response submitted (CY-BOCS, CGIS, PANS Scale); Post-transfusion purpura: medically necessary for post-transfusion purpura; Rasmussen encephalitis: medically necessary for members whose symptoms do not improve with anti-epileptic drugs and corticosteroids; Renal transplantation: medically necessary for member undergoing renal transplantation from a live donor with ABO incompatibility or positive cross match; Retinocochleocerebral vasculopathy, central nervous system-predominant (Susac syndrome): medically necessary when used as an adjunctive therapy to corticosteroid and other treatment options; Secondary immunosuppression associated with major surgery, hematological malignancy, extensive burns, or collagen-vascular disease: medically necessary to prevent or modify recurrent bacterial or viral infections in members with secondary immunosuppression (IgG < 400 mg/dL); Solid organ transplantation: medically necessary for allosensitized members; Toxic epidermal necrolysis and Stevens-Johnson syndrome: medically necessary for severe cases; Toxic shock syndrome: medically necessary when the infection is refractory to several hours of aggressive therapy, an undrainable focus is present, or the member has persistent oliguria with pulmonary edema; Systemic lupus erythematosus (SLE): medically necessary for severe, active SLE in members who have experienced inadequate response, intolerance, or have a contraindication to first- and second-line therapies (e.g., hydroxychloroquine, glucocorticoids, anifrolumab, rituximab); Measles (rubeola) prophylaxis: medically necessary for postexposure prophylaxis to prevent or modify symptoms in susceptible members exposed to the disease less than 6 days previously; Tetanus treatment and prophylaxis: medically necessary as an alternative when tetanus immune globulin (TIG) is unavailable; Varicella prophylaxis: medically necessary for postexposure prophylaxis of varicella in susceptible individuals when varicella-zoster immune globulin (VZIG) is unavailable; Toxic necrotizing fasciitis due to Group A Streptococcus: medically necessary for members with fasciitis due to invasive streptococcal infection; Continuation of IVIG or SCIG therapy (general rule): medically necessary when EITHER (a) for conditions with specific continuation criteria above, the member meets the applicable continuation criteria; OR (b) for all other conditions, the member continues to meet the initial medical necessity criteria. Applies to 17 codes: 90283, 90284, J1459, J1551, J1554, J1555, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, J1575, J1576, J1599. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Prior authorization status is code-specific; this CPB is not an exact authorization source for every covered code. Check the Aetna precertification list or PA lookup for the exact code and plan context. Documentation: For continuation of primary immunodeficiency therapy, EITHER IgG trough levels must be monitored at least yearly and maintained at or above the lower range of normal for age (when applicable for indication), OR the prescriber will re-evaluate the dose of IVIG or SCIG and consider a dose adjustment (when appropriate); For ITP indications based upon high risk of bleeding, the member's risk factor(s) for bleeding (see Appendix) or reason requiring a rapid increase in platelets must be provided; For PANS/PANDAS initial therapy: documented objective assessment of baseline symptoms must be submitted (e.g., Children's Yale-Brown Obsessive-Compulsive Scale [CY-BOCS], CGIS, PANS Scale); For PANS/PANDAS continued therapy: documentation of objective clinical response to therapy must be submitted (e.g., CY-BOCS, CGIS, PANS Scale); For PANS/PANDAS: documentation that other causes of symptoms have been ruled out; Diagnosis confirmation by genetic/molecular testing where applicable (e.g., SCID, Wiskott-Aldrich, DiGeorge, ataxia-telangiectasia, other combined immunodeficiency); Diagnosis confirmation by electrodiagnostic studies (CIDP, MMN) or neurophysiology/EMG or anti-P/Q VGCC antibody testing (LEMS); Biopsy with pathology confirmation for autoimmune mucocutaneous blistering disease; Anti-GAD antibody testing for stiff-person syndrome. Policy exclusions and limitations: Aetna considers IVIG/SCIG experimental, investigational, or unproven for indications OTHER THAN those listed as covered above - a condition that is covered above remains covered even if it (or its ICD category) appears below (not an all-inclusive list): Aetna considers all other indications (beyond those listed as medically necessary) experimental, investigational, or unproven; Magnesium infusion as a pre-medication for IVIG infusion - experimental, investigational, or unproven; Clostridium difficile enterocolitis - not covered (experimental/investigational/unproven); Tuberculosis of lung - not covered; Diphtheritic myocarditis - not covered; Meningococcal myocarditis - not covered; Syphilitic heart involvement - not covered; Lyme disease - not covered; Hand-foot-mouth disease - not covered; Viral myocarditis - not covered; Toxoplasma myocarditis - not covered; Unspecified parasitic and infectious disease - not covered; Gastric enterovirus - not covered; Rituximab-associated chronic CNS enterovirus infection - not covered; Malignant neoplasm (except hematologic) - not covered; Malignant carcinoid tumor - not covered; Follicular lymphoma (other than secondary immunosuppression with IgG < 400 mg/dL associated with this hematological malignancy, which is covered) - not covered; Burkitt lymphoma (other than secondary immunosuppression with IgG < 400 mg/dL associated with this hematological malignancy, which is covered) - not covered; Waldenstrom macroglobulinemia (other than secondary immunosuppression with IgG < 400 mg/dL associated with this hematological malignancy, which is covered) - not covered; Plasmacytoma (other than secondary immunosuppression with IgG < 400 mg/dL associated with this hematological malignancy, which is covered) - not covered; Acute lymphoblastic leukemia (other than secondary immunosuppression with IgG < 400 mg/dL associated with this hematological malignancy, which is covered) - not covered; Acute myeloid leukemia (other than secondary immunosuppression with IgG < 400 mg/dL associated with this hematological malignancy, which is covered) - not covered; Chronic myeloid leukemia (other than secondary immunosuppression with IgG < 400 mg/dL associated with this hematological malignancy, which is covered) - not covered; Multifocal and multisystemic Langerhans-cell histiocytosis - not covered; Monoclonal gammopathy - not covered; Neoplasms of uncertain behavior of lymphoid tissue - not covered; Hemolytic-uremic syndrome - not covered; Aplastic anemia - not covered; Acquired von Willebrand disease - not covered; Hereditary deficiency of other clotting factors - not covered; Allergic purpura (Henoch-Schonlein) - not covered; Evans syndrome - not covered; Neutropenia (other than autoimmune neutropenia where treatment with G-CSF is not appropriate, which is covered) - not covered; Disease of blood and blood-forming organs unspecified - not covered; Defects in the complement system - not covered; Large granular lymphocytic mediated immune cytopenia - not covered; Sarcoidosis - not covered; Cryoglobulinemia - not covered; Immune reconstitution syndrome - not covered; Diabetes mellitus - not covered; Other sphingolipidosis - not covered; Krabbe disease - not covered; Metachromatic leukodystrophy - not covered; Mucopolysaccharidosis type II - not covered; Lesch-Nyhan syndrome - not covered; Other disorders of purine and pyrimidine metabolism - not covered; Cystic fibrosis - not covered; Alpha-1-antitrypsin deficiency - not covered; Other disorders of plasma-protein metabolism - not covered; Major depressive disorder - not covered; Obsessive-compulsive disorder (other than abrupt-onset OCD as part of pediatric acute-onset neuropsychiatric syndrome [PANS/PANDAS] meeting the listed criteria, which is covered) - not covered; Autistic disorder - not covered; Attention-deficit hyperactivity disorders - not covered; Tic disorder - not covered; Meningitis (infection in neonates) - not covered; Benign recurrent meningitis (Mollaret) - not covered; Encephalitis, myelitis, and encephalomyelitis (other than immune-checkpoint-inhibitor-associated encephalitis/transverse myelitis, and acute disseminated encephalomyelitis with insufficient response or contraindication to IV corticosteroids, which are covered) - not covered; Toxic encephalopathy - not covered; Limbic encephalitis - not covered; Huntington's disease - not covered; Amyotrophic lateral sclerosis - not covered; Parkinson's disease and secondary parkinsonism - not covered; Autoimmune dystonia - not covered; Alzheimer's disease - not covered; Multiple sclerosis - not covered; Neuromyelitis optica (Devic's syndrome) - not covered; Epilepsy and recurrent seizures - not covered; Narcolepsy and cataplexy - not covered; Disorders of multiple cranial nerves - not covered; Neuralgic amyotrophy (Parsonage-Aldren-Turner syndrome) - not covered; Hereditary motor and sensory neuropathy (Charcot-Marie-Tooth) - not covered; Idiopathic progressive neuropathy - not covered; Anti-myelin-associated glycoprotein (anti-MAG) neuropathy - not covered; Idiopathic autonomic neuropathy - not covered; Hereditary and idiopathic neuropathy unspecified - not covered; Drug-induced polyneuropathy (bortezomib-induced) - not covered; Polyneuropathy in diseases classified elsewhere - not covered; Myasthenia gravis without acute exacerbation (including ocular) (other than refractory myasthenia gravis after failure of 2 or more standard therapies, and short-term therapy for worsening weakness, acute exacerbation, or pre-operative management, which are covered) - not covered; Isaacs syndrome - not covered; Other specified myotonic disorders (neuromyotonia) - not covered; Critical illness myopathy (necrotizing myopathy) - not covered; Other idiopathic peripheral autonomic neuropathy - not covered; Disorder of the autonomic nervous system unspecified - not covered; Complex regional pain syndrome I (reflex sympathetic dystrophy) - not covered; Mitochondrial encephalopathy - not covered; Autoimmune encephalopathy - not covered; Vasculitic polyneuropathy - not covered; Orbital myositis - not covered; Scleritis - not covered; Iridocyclitis - not covered; Optic neuritis - not covered; Rheumatic fever without heart involvement - not covered; Rheumatic fever with heart involvement - not covered; Rheumatic chorea without heart involvement (Sydenham's chorea) - not covered; Myocarditis in diseases classified elsewhere - not covered; Other primary cardiomyopathies - not covered; Degos disease - not covered; Clarkson disease (systemic capillary leak syndrome) - not covered; Rheumatoid arthritis and other inflammatory polyarthropathies - not covered; Polyarteritis nodosa - not covered; Goodpasture's syndrome - not covered; Thrombotic microangiopathy - not covered; Wegener's granulomatosis - not covered; Other specified necrotizing vasculopathies - not covered; Systemic sclerosis (scleroderma) - not covered; Sicca syndrome (Sjogren's syndrome) - not covered; Anti-synthetase syndrome - not covered; Other myositis and fibromyalgia (other than steroid-refractory myositis as an immune checkpoint inhibitor [PD-1 or PD-L1] related toxicity meeting the listed criteria, which is covered) - not covered; Myalgia (other than steroid-refractory myalgias as an immune checkpoint inhibitor [PD-1 or PD-L1] related toxicity meeting the listed criteria, which is covered) - not covered; Relapsing polychondritis - not covered; Nephritis and nephrotic syndrome - not covered; Unspecified nephritic syndrome with diffuse membranous glomerulonephritis - not covered; Unspecified nephritic syndrome with diffuse mesangiocapillary glomerulonephritis - not covered; Acute kidney failure - not covered; Acute vaginitis (neutrophilic necrotizing vulvovaginitis) - not covered; Female infertility - not covered; Maternal care for rhesus isoimmunization - not covered; Maternal care for other isoimmunization - not covered; Pneumonia (not related to RSV) - not covered; Chronic sinusitis - not covered; Asthma - not covered; Other interstitial pulmonary diseases with fibrosis - not covered; Idiopathic pulmonary fibrosis - not covered; Respiratory bronchiolitis interstitial lung disease - not covered; Other specified interstitial pulmonary diseases - not covered; Diseases of stomach and duodenum - not covered; Noninfective enteritis and colitis - not covered; Vascular disorders of intestine - not covered; Other diseases of intestines - not covered; Idiopathic chronic serositis - not covered; Stomatitis and related lesions (oral ulcers) - not covered; Other diseases of lip and oral mucosa (oral ulcers) - not covered; Bullous disorders (other than autoimmune mucocutaneous blistering disease - e.g., pemphigus vulgaris, pemphigus foliaceus, bullous pemphigoid, mucous membrane pemphigoid, epidermolysis bullosa acquisita - meeting the listed criteria, which is covered) - not covered; Dermatitis unspecified (eczema NOS) (other than severe eczema in hyperimmunoglobulinemia E syndrome, which is covered) - not covered; Lichen planus (oral) - not covered; Other urticaria - not covered; Solar urticaria - not covered; Pyoderma gangrenosum - not covered; Calcinosis cutis - not covered; Livedoid vasculitis - not covered; Urticarial vasculitis - not covered; Febrile neutrophilic dermatosis (Sweet syndrome) - not covered; Reiter's disease - not covered; Tachycardia unspecified (orthostatic tachycardia syndrome) - not covered; Hemoptysis (diffuse alveolar hemorrhage) - not covered; Rash and other nonspecific skin eruption (implantation rash) - not covered; Fasciculation (cramp-fasciculation syndrome) - not covered; Chronic fatigue syndrome - not covered; Unspecified convulsions - not covered; Shock not elsewhere classified - not covered; Other and unspecified abnormal immunological findings in serum - not covered; Spinal cord injury - not covered; Adverse effect of antineoplastic and immunosuppressive drugs (other than moderate or severe immune checkpoint inhibitor [PD-1 or PD-L1] related toxicities meeting the listed criteria, which are covered) - not covered; Angioneurotic edema - not covered; COVID-19 - not covered; Personal history of diseases of the female genital tract - not covered; Personal history of complications of pregnancy, childbirth and puerperium - not covered. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.
Does Aetna require prior authorization for Intravenous Immunoglobulins (IVIG)?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Prior authorization status is code-specific; this CPB is not an exact authorization source for every covered code. Check the Aetna precertification list or PA lookup for the exact code and plan context. Documentation: For continuation of primary immunodeficiency therapy, EITHER IgG trough levels must be monitored at least yearly and maintained at or above the lower range of normal for age (when applicable for indication), OR the prescriber will re-evaluate the dose of IVIG or SCIG and consider a dose adjustment (when appropriate); For ITP indications based upon high risk of bleeding, the member's risk factor(s) for bleeding (see Appendix) or reason requiring a rapid increase in platelets must be provided; For PANS/PANDAS initial therapy: documented objective assessment of baseline symptoms must be submitted (e.g., Children's Yale-Brown Obsessive-Compulsive Scale [CY-BOCS], CGIS, PANS Scale); For PANS/PANDAS continued therapy: documentation of objective clinical response to therapy must be submitted (e.g., CY-BOCS, CGIS, PANS Scale); For PANS/PANDAS: documentation that other causes of symptoms have been ruled out; Diagnosis confirmation by genetic/molecular testing where applicable (e.g., SCID, Wiskott-Aldrich, DiGeorge, ataxia-telangiectasia, other combined immunodeficiency); Diagnosis confirmation by electrodiagnostic studies (CIDP, MMN) or neurophysiology/EMG or anti-P/Q VGCC antibody testing (LEMS); Biopsy with pathology confirmation for autoimmune mucocutaneous blistering disease; Anti-GAD antibody testing for stiff-person syndrome.
What does Aetna exclude for Intravenous Immunoglobulins (IVIG)?
Policy exclusions and limitations: Aetna considers IVIG/SCIG experimental, investigational, or unproven for indications OTHER THAN those listed as covered above - a condition that is covered above remains covered even if it (or its ICD category) appears below (not an all-inclusive list): Aetna considers all other indications (beyond those listed as medically necessary) experimental, investigational, or unproven; Magnesium infusion as a pre-medication for IVIG infusion - experimental, investigational, or unproven; Clostridium difficile enterocolitis - not covered (experimental/investigational/unproven); Tuberculosis of lung - not covered; Diphtheritic myocarditis - not covered; Meningococcal myocarditis - not covered; Syphilitic heart involvement - not covered; Lyme disease - not covered; Hand-foot-mouth disease - not covered; Viral myocarditis - not covered; Toxoplasma myocarditis - not covered; Unspecified parasitic and infectious disease - not covered; Gastric enterovirus - not covered; Rituximab-associated chronic CNS enterovirus infection - not covered; Malignant neoplasm (except hematologic) - not covered; Malignant carcinoid tumor - not covered; Follicular lymphoma (other than secondary immunosuppression with IgG < 400 mg/dL associated with this hematological malignancy, which is covered) - not covered; Burkitt lymphoma (other than secondary immunosuppression with IgG < 400 mg/dL associated with this hematological malignancy, which is covered) - not covered; Waldenstrom macroglobulinemia (other than secondary immunosuppression with IgG < 400 mg/dL associated with this hematological malignancy, which is covered) - not covered; Plasmacytoma (other than secondary immunosuppression with IgG < 400 mg/dL associated with this hematological malignancy, which is covered) - not covered; Acute lymphoblastic leukemia (other than secondary immunosuppression with IgG < 400 mg/dL associated with this hematological malignancy, which is covered) - not covered; Acute myeloid leukemia (other than secondary immunosuppression with IgG < 400 mg/dL associated with this hematological malignancy, which is covered) - not covered; Chronic myeloid leukemia (other than secondary immunosuppression with IgG < 400 mg/dL associated with this hematological malignancy, which is covered) - not covered; Multifocal and multisystemic Langerhans-cell histiocytosis - not covered; Monoclonal gammopathy - not covered; Neoplasms of uncertain behavior of lymphoid tissue - not covered; Hemolytic-uremic syndrome - not covered; Aplastic anemia - not covered; Acquired von Willebrand disease - not covered; Hereditary deficiency of other clotting factors - not covered; Allergic purpura (Henoch-Schonlein) - not covered; Evans syndrome - not covered; Neutropenia (other than autoimmune neutropenia where treatment with G-CSF is not appropriate, which is covered) - not covered; Disease of blood and blood-forming organs unspecified - not covered; Defects in the complement system - not covered; Large granular lymphocytic mediated immune cytopenia - not covered; Sarcoidosis - not covered; Cryoglobulinemia - not covered; Immune reconstitution syndrome - not covered; Diabetes mellitus - not covered; Other sphingolipidosis - not covered; Krabbe disease - not covered; Metachromatic leukodystrophy - not covered; Mucopolysaccharidosis type II - not covered; Lesch-Nyhan syndrome - not covered; Other disorders of purine and pyrimidine metabolism - not covered; Cystic fibrosis - not covered; Alpha-1-antitrypsin deficiency - not covered; Other disorders of plasma-protein metabolism - not covered; Major depressive disorder - not covered; Obsessive-compulsive disorder (other than abrupt-onset OCD as part of pediatric acute-onset neuropsychiatric syndrome [PANS/PANDAS] meeting the listed criteria, which is covered) - not covered; Autistic disorder - not covered; Attention-deficit hyperactivity disorders - not covered; Tic disorder - not covered; Meningitis (infection in neonates) - not covered; Benign recurrent meningitis (Mollaret) - not covered; Encephalitis, myelitis, and encephalomyelitis (other than immune-checkpoint-inhibitor-associated encephalitis/transverse myelitis, and acute disseminated encephalomyelitis with insufficient response or contraindication to IV corticosteroids, which are covered) - not covered; Toxic encephalopathy - not covered; Limbic encephalitis - not covered; Huntington's disease - not covered; Amyotrophic lateral sclerosis - not covered; Parkinson's disease and secondary parkinsonism - not covered; Autoimmune dystonia - not covered; Alzheimer's disease - not covered; Multiple sclerosis - not covered; Neuromyelitis optica (Devic's syndrome) - not covered; Epilepsy and recurrent seizures - not covered; Narcolepsy and cataplexy - not covered; Disorders of multiple cranial nerves - not covered; Neuralgic amyotrophy (Parsonage-Aldren-Turner syndrome) - not covered; Hereditary motor and sensory neuropathy (Charcot-Marie-Tooth) - not covered; Idiopathic progressive neuropathy - not covered; Anti-myelin-associated glycoprotein (anti-MAG) neuropathy - not covered; Idiopathic autonomic neuropathy - not covered; Hereditary and idiopathic neuropathy unspecified - not covered; Drug-induced polyneuropathy (bortezomib-induced) - not covered; Polyneuropathy in diseases classified elsewhere - not covered; Myasthenia gravis without acute exacerbation (including ocular) (other than refractory myasthenia gravis after failure of 2 or more standard therapies, and short-term therapy for worsening weakness, acute exacerbation, or pre-operative management, which are covered) - not covered; Isaacs syndrome - not covered; Other specified myotonic disorders (neuromyotonia) - not covered; Critical illness myopathy (necrotizing myopathy) - not covered; Other idiopathic peripheral autonomic neuropathy - not covered; Disorder of the autonomic nervous system unspecified - not covered; Complex regional pain syndrome I (reflex sympathetic dystrophy) - not covered; Mitochondrial encephalopathy - not covered; Autoimmune encephalopathy - not covered; Vasculitic polyneuropathy - not covered; Orbital myositis - not covered; Scleritis - not covered; Iridocyclitis - not covered; Optic neuritis - not covered; Rheumatic fever without heart involvement - not covered; Rheumatic fever with heart involvement - not covered; Rheumatic chorea without heart involvement (Sydenham's chorea) - not covered; Myocarditis in diseases classified elsewhere - not covered; Other primary cardiomyopathies - not covered; Degos disease - not covered; Clarkson disease (systemic capillary leak syndrome) - not covered; Rheumatoid arthritis and other inflammatory polyarthropathies - not covered; Polyarteritis nodosa - not covered; Goodpasture's syndrome - not covered; Thrombotic microangiopathy - not covered; Wegener's granulomatosis - not covered; Other specified necrotizing vasculopathies - not covered; Systemic sclerosis (scleroderma) - not covered; Sicca syndrome (Sjogren's syndrome) - not covered; Anti-synthetase syndrome - not covered; Other myositis and fibromyalgia (other than steroid-refractory myositis as an immune checkpoint inhibitor [PD-1 or PD-L1] related toxicity meeting the listed criteria, which is covered) - not covered; Myalgia (other than steroid-refractory myalgias as an immune checkpoint inhibitor [PD-1 or PD-L1] related toxicity meeting the listed criteria, which is covered) - not covered; Relapsing polychondritis - not covered; Nephritis and nephrotic syndrome - not covered; Unspecified nephritic syndrome with diffuse membranous glomerulonephritis - not covered; Unspecified nephritic syndrome with diffuse mesangiocapillary glomerulonephritis - not covered; Acute kidney failure - not covered; Acute vaginitis (neutrophilic necrotizing vulvovaginitis) - not covered; Female infertility - not covered; Maternal care for rhesus isoimmunization - not covered; Maternal care for other isoimmunization - not covered; Pneumonia (not related to RSV) - not covered; Chronic sinusitis - not covered; Asthma - not covered; Other interstitial pulmonary diseases with fibrosis - not covered; Idiopathic pulmonary fibrosis - not covered; Respiratory bronchiolitis interstitial lung disease - not covered; Other specified interstitial pulmonary diseases - not covered; Diseases of stomach and duodenum - not covered; Noninfective enteritis and colitis - not covered; Vascular disorders of intestine - not covered; Other diseases of intestines - not covered; Idiopathic chronic serositis - not covered; Stomatitis and related lesions (oral ulcers) - not covered; Other diseases of lip and oral mucosa (oral ulcers) - not covered; Bullous disorders (other than autoimmune mucocutaneous blistering disease - e.g., pemphigus vulgaris, pemphigus foliaceus, bullous pemphigoid, mucous membrane pemphigoid, epidermolysis bullosa acquisita - meeting the listed criteria, which is covered) - not covered; Dermatitis unspecified (eczema NOS) (other than severe eczema in hyperimmunoglobulinemia E syndrome, which is covered) - not covered; Lichen planus (oral) - not covered; Other urticaria - not covered; Solar urticaria - not covered; Pyoderma gangrenosum - not covered; Calcinosis cutis - not covered; Livedoid vasculitis - not covered; Urticarial vasculitis - not covered; Febrile neutrophilic dermatosis (Sweet syndrome) - not covered; Reiter's disease - not covered; Tachycardia unspecified (orthostatic tachycardia syndrome) - not covered; Hemoptysis (diffuse alveolar hemorrhage) - not covered; Rash and other nonspecific skin eruption (implantation rash) - not covered; Fasciculation (cramp-fasciculation syndrome) - not covered; Chronic fatigue syndrome - not covered; Unspecified convulsions - not covered; Shock not elsewhere classified - not covered; Other and unspecified abnormal immunological findings in serum - not covered; Spinal cord injury - not covered; Adverse effect of antineoplastic and immunosuppressive drugs (other than moderate or severe immune checkpoint inhibitor [PD-1 or PD-L1] related toxicities meeting the listed criteria, which are covered) - not covered; Angioneurotic edema - not covered; COVID-19 - not covered; Personal history of diseases of the female genital tract - not covered; Personal history of complications of pregnancy, childbirth and puerperium - not covered. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source

Aetna CPB 0206 — Intravenous Immunoglobulins (IVIG)

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0206 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.