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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules state that the following are indications of Intravenous Immunoglobulin:

1. The treatment of primary immunodeficiency syndromes associated with defects in humoral immunity to
replace or boost immunoglobulin G (IgG)
2. The treatment of idiopathic thrombocytopenic purpura (ITP) when a rapid rise in the platelet count is
required such as prior to surgery, to control excessive bleeding, or to defer or avoid splenectomy
3. Treatment of Kawasaki disease, in conjunction with aspirin
4. Prevention of recurrent bacterial infections in patients with hypogammaglobulinemia associated with B-cell
chronic lymphocytic leukemia (CLL)
5. Decreasing risk of acute graft-vs.-host disease, associated interstitial pneumonia, and infections after bone
marrow transplant in the first 100 days after transplantation
6. Reducing the risk of severe bacterial infections in human immunodeficiency virus (HIV) infected children
with a CD4 count of greater than 200 to 400
7. Second-line treatment of dermatomyositis
8. The treatment of adults with Guillain-Barr syndrome diagnosed within the first 2 weeks of illness
9. Treatment of hyperimmunoglobulinemia E syndrome and Lambert-Eaton myasthenic syndrome (LEMS)
10. Treatment of multifocal motor neuropathy (MMN)
11. Treatment of relapsing-remitting multiple sclerosis
12. Treatment of chronic parvovirus B19 infection and severe anemia associated with bone marrow suppression
and pure red cell aplasia
13. Treatment of progressive pemphigus vulgaris, pemphigus foliaceus, bullous pemphigoid, mucous
membrane pemphigoid, and epidermolysis bullosa acquisita in patients that have failed conventional
treatment and patients in whom conventional therapy is otherwise contraindicated
14. For coverage criteria of Autoimmune Mucocutaneous Blistering Diseases, please see CMS Internet-Only
Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, 250.3
15. Treatment of stiff person syndrome
16. Treatment of Myasthenia Gravis (MG) in patients who have profound, rapidly progressive and/or
potentially life-threatening muscular weakness and are refractory to, or intolerant of cholinesterase
inhibitors, corticosteroids and azathioprine
17. The prevention and/or treatment of organ rejection in patients sensitized to living or cadaveric organ donors
18. Schonlein-Henoch
19. Treatment of Paraneoplastic Visual Loss
20. Treatment of Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) in patients meeting the necessary criteria
21. Treatment of Multiple Myeloma for the prevention of life-threatening infections due to reduced gamma globulins

You can find these rules in the Local Coverage Determination (LCD) for Intravenous Immunoglobulin (IVIG), L34580.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.