Intravenous Immune Globulin (IVIg) - NCD 250.3

This article describes CMS national coverage effective on/after October 1, 2001. Please see the Noridian Local Coverage Determination for additional indications.

Patient must meet at least one of the following criteria:

  • Failed conventional therapy. Contractors have the discretion to define what constitutes failure of conventional therapy;
  • Conventional therapy is contraindicated. Contractors have the discretion to define what constitutes contraindications to conventional therapy; or
  • Have rapidly progressive disease in which a clinical response could not be affected quickly enough using conventional agents. In these situations, IVIg therapy would be give along with conventional treatment(s) and the IVIg would be used only until conventional therapy could take effect.

Note: In addition, IVIg for the treatment of autoimmune mucocutaneous blistering disease must be used only for short term therapy and not as a maintenance therapy. Again, contractors have the discretion to decide what constitutes short-term therapy.

The following diagnosis codes are appropriate. Intravenous immune globulin (IVIg) is covered nationally for the treatment of the following biopsy-proven conditions:

ICD-10-CM Code Description
L10.0 Pemphigus vulgaris
L10.1 Pemphigus vegetans
L10.2 Pemphigus foliaceous
L10.3 Brazilian pemphigus [fogo selvagem]
L10.4 Pemphigus erythematosus
L10.5 Drug-induced pemphigus
L10.81 Paraneoplastic pemphigus
L10.89 Other pemphigus
L10.9 Pemphigus, unspecified
L12.0 Bullous pemphigoid
L12.1 Cicatricial pemphigoid
L12.8 Other pemphigoid
L12.9 Pemphigoid, unspecified
L13.8 Other specified bullous disorders

 

Effective Date Changes Implemented
05/20/2015 R1 -  Diagnosis L14 is deleted effective 5/20/2015 per CR 9252, dated 12/3/2015. The Part A article is retired and Part A contract numbers are added to the Part B article.

 

Last Updated Oct 25, 2018