Immune Globulin (IVIG and SCIG) (for Indiana Only)
UnitedHealthcare Medical Benefit Drug Policy applicable only to Indiana governing coverage of intravenous and subcutaneous immune globulin products (IVIG/SCIG). It defers medical necessity clinical coverage criteria to the current InterQual guideline and lists applicable procedure and HCPCS/J-codes for reference.
Coverage Rationale: Added instruction to refer to the current InterQual guideline for medical necessity clinical coverage criteria for Alyglo and Yimmugo.
Archived previous policy version CSIND0035.07 from active status.
Coverage Summary
Policy CSIND0035.08 applies to intravenous and subcutaneous immune globulin products (IVIG and SCIG) for Indiana. Medical necessity determinations are delegated to and must follow the current InterQual clinical coverage policy (CP) for Specialty Rx Non-Oncology immune globulin. The policy lists procedure and HCPCS/J-codes for reference only; inclusion of codes does not guarantee coverage or payment.