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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 say that medically necessary services are those that are reasonable and necessary for the diagnosis or
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A).
The rules say that indications for intravenous immunoglobulin (IVIG) are:
 The treatment of primary immunodeficiency syndromes associated with defects in humoral immunity to
replace or boost immunoglobulin G (IgG)
 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
 Treatment of Kawasaki disease, in conjunction with aspirin
 Prevention of recurrent bacterial infections in patients with hypogammaglobulinemia associated with B-
cell chronic lymphocytic leukemia (CLL)
 Decreasing risk of acute graft-vs.-host disease, associated interstitial pneumonia, and infections after
bone marrow transplant in the first 100 days after transplantation
 Reducing the risk of severe bacterial infections in human immunodeficiency virus (HIV) infected
children with a CD4 count of greater than 200 to 400
 Second-line treatment of dermatomyositis
 The treatment of adults with Guillain-Barre syndrome diagnosed within the first 2 weeks of illness
 Treatment of hyperimmunoglobulinemia E syndrome and Lambert-Eaton myasthenic syndrome
(LEMS)
 Treatment of multifocal motor neuropathy (MMN)
 Treatment of relapsing-remitting multiple sclerosis
 Treatment of chronic parvovirus B19 infection and severe anemia associated with bone marrow
suppression and pure red cell aplasia
 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
 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,
Section 250.3
 Treatment of stiff person syndrome
 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
 The prevention and/or treatment of organ rejection in patients sensitized to living or cadaveric organ
donors
 Schonlein-Henoch
 Treatment of Paraneoplastic Visual Loss
 Treatment of Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) in patients meeting the
necessary criteria
 Treatment of Multiple Myeloma for the prevention of life-threatening infections due to reduced gamma
globulins
You can find this rule in the Local Coverage Determination for Intravenous Immunoglobulin (IVIG), L34580
(eff 10/04/20).
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.