CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Payment Policy PANDAS and PANS Mandate

State-mandated coverage guidelines for treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) and pediatric acute-onset neuropsychiatric syndrome (PANS) for Blue Cross & Blue Shield of Rhode Island products; indicates coverage includes, but is not limited to, intravenous immunoglobulin (IVIG).

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPayment Policy PANDAS and PANS Mandate

Policy CodePolicy N/A

Change TypeAdoption of state mandate (added)

Effective DateJan 1, 2023

Next Review Date

Key ActionCheck plan-specific prior authorization requirements and verify member benefits and document medical necessity before providing services.

SourceLink

POLICY UPDATE CHANGES

Adoption of Rhode Island RIGL 27-18-89 mandated coverage for treatment of PANDAS and PANS including IVIG.

1Mandated condition(s) covered (PANDAS/PANS)

1Specific therapy named (IVIG)

3Plans possibly exempted but adopted

0.86Confidence score

Coverage Summary

State-mandated coverage guidelines for treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) and pediatric acute-onset neuropsychiatric syndrome (PANS) for Blue Cross & Blue Shield of Rhode Island products. Coverage stance: covered_with_criteria. Effective date: 2023-01-01; Policy last review: 2023-01-01. Coverage includes, but is not limited to, intravenous immunoglobulin (IVIG) per Rhode Island General Law 27-18-89.

Effective Date01/01/2023

Last Review01/2023

Coverage StanceCovered with criteria (state-mandated coverage for PANDAS/PANS, including IVIG)

Named TherapyIntravenous immunoglobulin (IVIG) explicitly included

Scope SummaryState-mandated coverage guidelines for treatment of PANDAS and PANS for BCBSRI insured products; benefits may vary by group/contract and Plan 65, FEP, and Medicare Advantage are generally exempt but BCBSRI has adopted the requirements for insured products.

Policy Statement / Medical Criteria

Coverage is provided in accordance with Rhode Island General Law 27-18-89; Medical criteria: Not applicable

ALL of the following

Coverage is provided for the treatment of PANDAS and PANS in accordance with RIGL 27-18-89, including but not limited to the use of intravenous immunoglobulin (IVIG).
Benefits may vary by group/contract; refer to member's Benefit Booklet/Evidence of Coverage/Subscriber Agreement for applicable benefits/coverage.
Although Rhode Island-mandated benefits generally do not apply to Plan 65, FEP, and Medicare Advantage Plans, BCBSRI has adopted these coverage requirements for all insured products.

Medical criteria: Not applicable

Diagnosis Coding Guidance

Diagnosis coding guidanceICD-10

autoimmune encephalitis (use until specific codes assigned)

Guidance: PANDAS and PANS shall be coded as autoimmune encephalitis until AMA and CMS create and assign specific codes; thereafter may be coded as autoimmune encephalitis, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, or pediatric acute onset neuropsychiatric syndrome.

Billing Rule

Diagnosis coding until specific codes exist

For coding and billing, code PANDAS/PANS as autoimmune encephalitis until the AMA and CMS create and assign specific codes. Update coding to the specific pediatric PANDAS/PANS codes when they become available.

Provider Actions & Requirements

Prior Authorization

Prior authorization may be required

Some services used to treat PANDAS/PANS (including IVIG) may require prior authorization. Check plan-specific authorization requirements and the member's benefits before providing services.

Documentation Required

Benefit verification and documentation

Verify member-specific benefits, eligibility, and plan exclusions in the member's Evidence of Coverage or Subscriber Agreement prior to providing services. Document medical necessity as required by the plan.

Background

This policy implements Rhode Island General Law (RIGL) 27-18-89, which requires group health plans delivered, issued for delivery, or renewed in the state on or after January 1, 2023 to provide coverage for treatment of PANDAS and PANS, including but not limited to intravenous immunoglobulin (IVIG). PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections) is a subset of PANS characterized by sudden onset or exacerbation of obsessive-compulsive disorder (OCD) and/or tics associated with streptococcal (strep) infection; symptoms are often severe enough to interfere with functioning. For coding purposes, PANDAS/PANS should be coded as autoimmune encephalitis until specific AMA/CMS codes are assigned.

Definitions

Policy scope notes