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Decision: unknown

 
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 off-label indications for intravenous immune globulin (IVIG) products will be considered 
medically reasonable and necessary in the following situations: 
     1. Multiple myeloma for recurrent infections with hypogammaglobulinemia and subprotective antibody 
 levels following immunization against diphtheria, tetanus or pneumococcal infection.    
     2.    Following treatment of lymphoma utilizing B-cell depleting therapies for recurrent infections with 
 hypogammaglobulinemia and subprotective antibody levels following immunization against diphtheria, 
 tetanus or pneumococcal infection. 
     3. Recipients of hematopoietic stem cell transplants with severe combined immunodeficiency (SCID) or 
 other primary immunodeficiencies who are functionally agammaglobulinemic because of weak B-cell 
 engraftment. 
     4. Recipients of allogeneic hematopoietic stem cell transplantation with chronic graft versus host disease 
 (GVHD), recurring bacterial infections, and subprotective antibody levels following immunization 
 against diphtheria, tetanus or pneumococcal infection. 
     5. Human Leukocyte Antigen (HLA) and ABO desensitization protocols for the prevention of acute 
 humoral rejection in renal transplantation. 
     6. The treatment of antibody mediated solid organ transplant rejection in combination with rituximab and 
 plasma exchange (PE). 
     7. Treatment of hypogammaglobulinemia in solid organ transplants. 
     8. Autoimmune hemolytic anemia (AIHA) when other treatment approaches have failed. 
     9. Systemic capillary leak syndrome (SCLS). 
     10. Guillain-Barre syndrome (GBS) in adults. 
     11. Moderate to severe myasthenia gravis (MG). 
     12. Lambert-Eaton myasthenic syndrome (LEMS) in individuals who fail to respond or do not tolerate 
 other treatments. 
     13. Relapsing-remitting multiple sclerosis (MS). 
     14. Neuromyelitis optica (Devic syndrome) in individuals with severe relapses not responding to 
 corticosteroids and who are not candidates for PE3. 
     15. Stiff-person syndrome (also referred to as stiff-man syndrome). 
     16. Treatment of autoimmune encephalitis, once infection is ruled out, as an alternative in patients who fail  to respond or do not tolerate other treatments. 
     17. Treatment of Susac syndrome in combination with high-dose intravenous corticosteroids. 
     18. Severe forms of polymyositis resistant to treatment with glucocorticosteroids and immunosuppressants. 
     19. Severe forms of inclusion body myositis with dysphagia and individuals are otherwise treatment-
 resistant. 
     20. Immune mediated necrotizing myopathy resistant to treatment with glucocorticosteroids and 
 immunosuppressants. 
     21. Overlap syndrome with myositis including anti-synthetase syndrome resistant to treatment with 
 glucocorticosteroids and immunosuppressants. 
     22. Severe systemic lupus erythematosus (SLE) in individuals who fail to respond or do not tolerate other 
 treatments. 
     23. Biopsy-proven autoimmune mucocutaneous blistering diseases in individuals who fail to respond or do 
 not tolerate other treatments and individuals with rapidly progressive disease requiring a faster response 
 than conventional therapy (i.e., pemphigus vulgaris, pemphigus foliaceus, bullous pemphigoid, mucous 
 membrane pemphigoid and epidermolysis bullosa acquisita). 
     24. Toxic epidermal necrolysis (TEN). 
     25. Stevens-Johnson syndrome. 
     26. Severe scleromyxedema. 
     27. Thyroid eye disease, also referred to as Graves disease in patients who have failed treatment with 
 teprotumumab or have contraindications to the use of teprotumumab. 
 
The following are considered not medically reasonable and necessary: 
      - The off-label use of intravenous immune globulin not listed above in the covered indications AND 
Immune globulin for Brachial plexopathy. 
 
You can find these rules Local Coverage Determination (LCD) Immune Globulin (L35093). 
 
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.