IVIG for Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)
Criteria and prior authorization form governing coverage of intravenous immune globulin (IVIG) for members with CIDP, including required documentation and step therapy for AvMed members and prescribers.
No material clinical or coverage changes in this revision.
Coverage Criteria for IVIG in CIDP
Initial IVIG for CIDP
Covered when ALL of the following are met
submit documentation (chart notes, diagnosis, EFNS/PNS justification)
Electrodiagnostic evidence
- Demyelination criteria (select criteria to document): Partial motor conduction block in ≥2 motor nerves or in 1 nerve plus one other demyelination criterion in ≥1 other nerve; distal CMAP duration increase in ≥1 nerve plus one other demyelination criterion in ≥1 other nerve; abnormal temporal dispersion in ≥2 motor nerves; reduced motor conduction velocity in ≥2 motor nerves; prolonged distal motor latency in ≥2 motor nerves; absent F wave in ≥2 motor nerves plus one other demyelination criterion in ≥1 other nerve; prolonged F wave latency in ≥2 motor nerves; >30% proximal CMAP amplitude reduction relative to distal in two nerves (excluding posterior tibial when distal CMAP >20% LLN) or in one nerve plus >1 other demyelinating parameter in >1 other nerve.
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