CurrentClover HealthPolicy 4807-A

Intramuscular Immune Globulin Coverage Criteria

Customize your policy alerts

Sign up for clover_health Policy 4807-A alerts

Get alerted when Policy 4807-A changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This policy governs Medicare Part B coverage and prior authorization for intramuscular immune globulin, including GamaSTAN, for specified infectious-disease exposures and immunoglobulin deficiency. Coverage applies in the listed jurisdiction states when approval criteria are met and the member has no exclusions to the prescribed therapy.

Policy Summary

PayerClover Health

PolicyIntramuscular Immune Globulin Coverage Criteria

Policy CodePolicy 4807-A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit supporting evidence from Medicare-approved compendia for indications not enumerated in the policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5Covered indication categories

1 monthAuthorization duration

6Jurisdiction states

Individual reviewNon-enumerated indications

Covered Indications and Eligibility

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentClover HealthPolicy 4807-A

Intramuscular Immune Globulin Coverage Criteria

Customize your policy alerts

Sign up for clover_health Policy 4807-A alerts

Get alerted when Policy 4807-A changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerClover Health

PolicyIntramuscular Immune Globulin Coverage Criteria

Policy CodePolicy 4807-A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit supporting evidence from Medicare-approved compendia for indications not enumerated in the policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5Covered indication categories

1 monthAuthorization duration

6Jurisdiction states

Individual reviewNon-enumerated indications

Covered Indications and Eligibility

Hepatitis A Exposure

Authorization may be granted for 1 month.

Hepatitis A exposure: The member has hepatitis A exposure.

Measles (Rubeola)

Authorization may be granted for 1 month when all of the following criteria are met.

Measles criteria

Vaccination or prior disease and risk: The member is unvaccinated or had measles and is at high risk for complications.
Recent exposure: The member has been exposed to measles less than three days prior to treatment.< 3 days

Rubella

Authorization may be granted for 1 month when all of the following criteria are met.

Rubella criteria

Early pregnancy: The member is in early pregnancy.
Exposure without immunity: The member has been exposed to the virus and does not have immunity.

Varicella

Authorization may be granted for 1 month when all of the following criteria are met.

Varicella passive immunization criteria

Immunosuppression: The member is immunosuppressed.
Product unavailable: Varicella zoster immunoglobulin is not available.

Immunoglobulin Deficiency

Authorization may be granted for 1 month.

Immunoglobulin deficiency criteria

Low IgG: The member's circulating IgG levels are low.Low
Treatment purpose: Treatment is for prevention of serious infection.

Coverage requires that all applicable approval criteria are met and that the member has no exclusions to the prescribed therapy. Members with exclusions are not eligible for coverage.

Authorization and Submission Guidance

Prior Authorization

Hepatitis A Exposure Authorization

Authorization of 1 month may be granted for hepatitis A exposure.

Prior Authorization

Measles Authorization

Authorization of 1 month may be granted for measles when the member is unvaccinated or has had measles and is at high risk for complications, and was exposed less than three days before treatment.

Prior Authorization

Rubella Authorization

Authorization of 1 month may be granted for rubella when the member is in early pregnancy, has been exposed to the virus, and does not have immunity.

Prior Authorization

Varicella Passive Immunization Authorization

Authorization of 1 month may be granted for passive immunization of varicella when the member is immunosuppressed and varicella zoster immunoglobulin is not available.

Prior Authorization

Immunoglobulin Deficiency Authorization

Authorization of 1 month may be granted for prevention of serious infection when the member's circulating IgG levels are low.

Unsupported block type: documentation

Denial Risk

Indication Not Supported by Policy

A requested indication that is not enumerated in this policy may be denied unless it is assessed individually.

Denial Risk

Approval Criteria and Exclusions

Covered use requires that all applicable approval criteria are met and that the member has no exclusions to the prescribed therapy.

Policy Scope

This policy addresses intramuscular immune globulin for post-exposure or passive-immunization-related uses involving hepatitis A, measles, rubella, and varicella. It also addresses prevention of serious infection in members with immunoglobulin deficiency and low circulating IgG levels. Other indications are assessed individually and should be supported by evidence from Medicare-approved compendia.

Initial Therapy Decision Criteria

Hepatitis A Exposure

Authorization may be granted for 1 month for hepatitis A exposure.

Hepatitis A exposure: The member has hepatitis A exposure.

Measles

Authorization may be granted for 1 month when all criteria are met.

Vaccination or prior disease and risk: The member is unvaccinated or had measles and is at high risk for complications.
Recent exposure: The member has been exposed to measles less than three days prior to treatment.< 3 days

Rubella

Authorization may be granted for 1 month when all criteria are met.

Early pregnancy: The member is in early pregnancy.
Exposure without immunity: The member has been exposed to the virus and does not have immunity.

Varicella

Authorization may be granted for 1 month when all criteria are met.

Immunosuppression: The member is immunosuppressed.
Product unavailable: Varicella zoster immunoglobulin is not available.

Immunoglobulin Deficiency

Authorization may be granted for 1 month for prevention of serious infection.

Immunoglobulin deficiency

Low IgG: The member's circulating IgG levels are low.Low circulating IgG
Treatment purpose: Treatment is for prevention of serious infection.

Policy Summary

PayerClover Health

PolicyIntramuscular Immune Globulin Coverage Criteria

Policy CodePolicy 4807-A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit supporting evidence from Medicare-approved compendia for indications not enumerated in the policy.

SourceLink

On This Page

Intramuscular Immune Globulin Coverage Criteria

Sign up for clover_health Policy 4807-A alerts

Covered Indications and Eligibility

Intramuscular Immune Globulin Coverage Criteria

Sign up for clover_health Policy 4807-A alerts

Covered Indications and Eligibility

Clinical Thresholds and Timing

Authorization and Submission Guidance

Policy Scope

Initial Therapy Decision Criteria