Required Coverage for Treatment of PANDAS and PANS
Customize your policy alerts
Sign up for all Health Care Access Bureau and Bureau of Managed Care, Division of Insurance policy alerts
Know when Health Care Access Bureau and Bureau of Managed Care, Division of Insurance releases new policies or updates existing guidance.
Monitor payer policy activity
Bulletin directing Massachusetts commercial carriers and HMOs to provide coverage for medically necessary treatment of PANDAS and PANS, including IVIG, for insured plans issued or renewed in Massachusetts on or after January 1, 2022, and to ensure network access or temporarily cover out-of-network providers in‑network.
Carriers must provide coverage for treatment of PANDAS and PANS, including but not limited to intravenous immunoglobulin (IVIG) therapy.
Requirement that the statutory provisions apply to insured health benefit plans issued or renewed in Massachusetts on or after January 1, 2022.
Carriers must notify network providers and covered members, update administrative processes, identify in-network PANDAS/PANS providers, and cover out-of-network providers in-network if network access is inadequate.
When Services Are Covered
Medically necessary treatment for PANDAS/PANS
Covered when medically necessary for PANDAS or PANS patients
Applies to insured health benefit plans issued or renewed in Massachusetts on or after January 1, 2022.
This bulletin implements the statutory requirement created by Chapter 260 that carriers must provide coverage for treatment of PANDAS and PANS. The statute specifically states coverage must include, but is not limited to, the use of intravenous immunoglobulin (IVIG) therapy for these conditions. The statutory provisions apply to insured health benefit plans that are issued or renewed in Massachusetts on or after January 1, 2022.
Carriers are directed to align their coverage policies and administrative processes with the new statutory sections referenced in this bulletin. In addition to providing coverage for medically necessary PANDAS/PANS treatments including IVIG, carriers should ensure network adequacy for providers who can diagnose and treat these pediatric neuropsychiatric disorders and take steps to notify affected members and providers of the coverage requirements.
If a carrier’s network does not include adequate access to clinicians who can provide medically necessary PANDAS/PANS services, the Division expects carriers to cover medically necessary services from out‑of‑network providers on an in‑network basis until adequate in‑network capacity is available. Carriers were also asked to identify and forward materials naming in‑network providers able to treat PANDAS/PANS to the Division by September 1, 2021.
What Carriers and Providers Must Do
Statutory coverage requirement: include IVIG
Carriers must provide coverage for treatment of PANDAS and PANS, including intravenous immunoglobulin (IVIG) therapy, consistent with Chapter 260; this coverage requirement applies to insured health benefit plans issued or renewed in Massachusetts on or after January 1, 2022.
- Statutory text: carriers “provide coverage for treatment of pediatric autoimmune neuropsychiatric disorders … including, but not limited to, the use of intravenous immunoglobulin therapy.”
- Effective date: provisions apply to plans issued or renewed in Massachusetts on or after January 1, 2022.
Notify providers/members and update processes
Carriers must notify network providers and covered members about PANDAS and PANS coverage and update administrative processes to enable access to medically necessary treatment for members both within and outside the Commonwealth.
- Notify network providers and covered members about PANDAS/PANS coverage.
- Update administrative processes to enable members to access medically necessary PANDAS/PANS treatment.
Identify in‑network PANDAS/PANS providers and report to the Division
Carriers are expected to identify providers in their networks who can provide medically necessary PANDAS and PANS services and to forward materials to the Division identifying the names and locations of such providers by September 1, 2021.
- Identify in‑network providers able to provide medically necessary PANDAS/PANS services.
- Forward materials to the Division by September 1, 2021 listing names and locations of those providers.
Cover out‑of‑network providers in‑network when access is inadequate
If a Carrier’s network does not include adequate access to providers who can treat PANDAS and PANS, the Carrier must cover medically necessary PANDAS and PANS services from out‑of‑network providers on an in‑network basis until an adequate network is developed.
- Temporary in‑network coverage applies to medically necessary services from out‑of‑network providers when network access is inadequate.
- This requirement remains until the Carrier develops an adequate in‑network provider network for PANDAS/PANS.
Key Terms
Covered Treatments and Modalities
IVIG — treatment-specific criteria
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.