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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 off-label indications for intravenous immune globulin (IVIG) products will be considered 
medically reasonable and necessary in the following situations: 
 
    Multiple myeloma for recurrent infections with hypogammaglobulinemia and subprotective antibody levels 
following immunization against diphtheria, tetanus or pneumococcal infection1,3,5-7 
    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 infection3 
    Recipients of hematopoietic stem cell transplants with severe combined immunodeficiency (SCID) or other 
primary immunodeficiencies who are functionally agammaglobulinemic because of weak B-cell engraftment3 
    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 infection3 
    Human Leukocyte Antigen (HLA) and ABO desensitization protocols for the prevention of acute humoral 
rejection in renal transplantation3 
    The treatment of antibody mediated solid organ transplant rejection in combination with rituximab and 
plasma exchange (PE)3,8 
    Treatment of hypogammaglobulinemia in solid organ transplants3 
    Autoimmune hemolytic anemia (AIHA) when other treatment approaches have failed9-10 
    Systemic capillary leak syndrome (SCLS)11-13 
    Guillain-Barre syndrome (GBS) in adults1,3,14-15 
    Moderate to severe myasthenia gravis (MG)2-3,10,15-18 
    Lambert-Eaton myasthenic syndrome (LEMS) in individuals who fail to respond or do not tolerate other 
treatments3 
    Relapsing-remitting multiple sclerosis (MS)3,19-22 
    Neuromyelitis optica (Devic syndrome) in individuals with severe relapses not responding to corticosteroids 
and who are not candidates for PE3 
    Stiff-person syndrome (also referred to as stiff-man syndrome)2-3 
    Treatment of autoimmune encephalitis, once infection is ruled out, as an alternative in patients who fail to respond or do not tolerate other treatments23-27 
    Treatment of Susac syndrome in combination with high-dose intravenous corticosteroids28 
    Severe forms of polymyositis resistant to treatment with glucocorticosteroids and immunosuppressants29-30 
    Severe forms of inclusion body myositis with dysphagia and individuals are otherwise treatment-
resistant3,29-33 
    Immune mediated necrotizing myopathy resistant to treatment with glucocorticosteroids and 
immunosuppressants29-30 
    Overlap syndrome with myositis including anti-synthetase syndrome resistant to treatment with 
glucocorticosteroids and immunosuppressants29-30 
    Severe systemic lupus erythematosus (SLE) in individuals who fail to respond or do not tolerate other 
treatments10,30 
    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)3,30,34-39 
    Toxic epidermal necrolysis (TEN)3,30 
    Stevens-Johnson syndrome3,30 
    Severe scleromyxedema3,30,40-41 
    Thyroid eye disease, also referred to as Graves disease in patients who have failed treatment with 
teprotumumab or have contraindications to the use of teprotumumab3,42-45 
 
You can find this information in the Local Coverage Determination (LCD) Immune Globulin L35093. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.