Immunoglobulin Medicare Guidelines

Documentation to include:

  • Diagnosis with ICD-10 code
  • Symptom history supporting diagnosis
  • Laboratory reports
  • Diagnostic reports

Intravenous immune globulin (IVIG) requires one of the below qualifying diagnoses:

  • Short-term new-onset CIDP (Chronic Inflammatory Demyelinating Polyneuropathy)
  • Short-term CIDP relapses
  • IVIG may be considered as an option in combination with other immunosuppressive therapy for the long-term management of CIDP.
    • The patient should be under the care of a qualified expert with specialized knowledge of CIDP and a systematic approach should be taken to determine the minimal effective dose

Subcutaneous immune globulin (SCIg) requires one of the below qualifying diagnoses:

  • PIDD (Primary Immune Deficiency Disorders)
  • CIDP (Chronic Inflammatory Demyelinating Polyneuropathy)
  • Approved ICD-10 codes for PIDD (Primary Immune Deficiency Disorders):
    • D80.0 Hereditary hypogammaglobulinemia
    • D80.2 Selective deficiency of immunoglobulin A [IgA]
    • D80.3 Selective deficiency of immunoglobulin G [IgG] subclasses
    • D80.4 Selective deficiency of immunoglobulin M [IgM]
    • D80.5 Immunodeficiency with increased immunoglobulin M [IgM]
    • D80.6 Antibody deficiency with near-normal immunoglobulins or with hyperimmunoglobulinemia
    • D80.7 Transient hypogammaglobulinemia of infancy
    • D81.0 Severe combined immunodeficiency [SCID] with reticular dysgenesis
    • D81.1 Severe combined immunodeficiency [SCID] with low T- and B-cell numbers
    • D81.2 Severe combined immunodeficiency [SCID] with low or normal B-cell numbers
    • D81.5 Purine nucleoside phosphorylase [PNP] deficiency
    • D81.6 Major histocompatibility complex class I deficiency
    • D81.7 Major histocompatibility complex class II deficiency
    • D81.89 Other combined immunodeficiencies
    • D81.9 Combined immunodeficiency, unspecified
    • D82.0 Wiskott-Aldrich syndrome
    • D82.1 Di George's syndrome
    • D82.4 Hyperimmunoglobulin E [IgE] syndrome
    • D83.0 Common variable immunodeficiency with predominant abnormalities of B-cell numbers and function
    • D83.1 Common variable immunodeficiency with predominant immunoregulatory T-cell disorders
    • D83.2 Common variable immunodeficiency with autoantibodies to B- or T-cells
    • D83.8 Other common variable immunodeficiencies
    • D83.9 Common variable immunodeficiency, unspecified G11.3 Cerebellar ataxia with defective DNA repair
  • Approved ICD-10 codes for CIDP (Chronic Inflammatory Demyelinating Polyneuropathy)
    • G61.81 Chronic inflammatory demyelinating polyneuritis
Chartwell reviews all eligible Medicare patients for infusion qualification based on the Noridian LCD found at: External Infusion Pumps LCD and PA ( Noridian has the most current and up to date information. Please refer to the Noridian site for clarification of any content on this site.

Some therapies will have fill and total dose limitations with each qualifying diagnosis. Some therapies will require an electronic external infusion pump, while others will prohibit use of an electronic pump based on the LCD. Medicare covers home infusion under their external infusion pump coverage within the Durable Medical Equipment benefit.

For qualification, provider documentation requires diagnostic testing to support diagnosis for all therapies requiring Medicare qualification. Additionally:
  • The patient must be eligible for a defined Medicare benefit category.
  • Therapy must be reasonable and necessary for the diagnosis and supported in medical documentation.
  • The case must meet all other applicable Medicare statutory and regulatory requirements.