CurrentUnitedHealthcarePolicy CSOH2025D0035.D

Immune Globulin (IVIG and SCIG) (for Ohio Only)

Ohio-specific UnitedHealthcare medical benefit drug policy governing coverage and medical necessity review for FDA‑approved intravenous and subcutaneous immune globulin products for members in Ohio.

Policy Summary

PayerUnitedHealthcare

PolicyImmune Globulin (IVIG and SCIG) (for Ohio Only)

Policy CodePolicy CSOH2025D0035.D

Change TypeAdded InterQual reference for listed products

Effective DateAug 1, 2025

Next Review Date

Key ActionRequest prior authorization using the current InterQual® guideline for the specific immune globulin product.

SourceLink

POLICY UPDATE CHANGES

Added instruction to refer to the current InterQual® guideline for Alyglo (IVIG) and Yimmugo (IVIG).

>=15listed products (examples)

Ohiostate

InterQualexternal guideline

90283–90284, J-codescodes referenced

Coverage Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

InterQual-based medical necessity: Medical necessity must meet the current InterQual® guideline for the specific immune globulin product requested.refer to InterQual® for product-specific criteria

Policy maps specific FDA‑approved IVIG and SCIG products to InterQual® criteria; when a product is not listed, use the product package insert dosing and applicable policy criteria.

The listing of procedure or drug codes in this policy is for reference only and does not by itself indicate that a service is covered. Benefit coverage and reimbursement are determined by applicable federal, state, or contractual requirements and laws; inclusion of a code does not guarantee coverage or payment and other policies or guidelines may apply.

Applicable Procedure and Drug Codes

Applicable procedure and drug codes (part 1)mixed

90283	Immune globulin (IgIV), human, for intravenous use.
90284	Immune globulin (SCIg), human, for use in subcutaneous infusions, 100 mg, each.
J1459	Injection, immune globulin (Privigen®), intravenous, nonlyophilized (e.g., liquid), 500 mg.
J1551	Injection, immune globulin (Cutaquig), 100 mg.
J1552	Injection, immune globulin (Alyglo), 500 mg.
J1554	Injection, immune globulin (Asceniv™), 500 mg.
J1555	Injection, immune globulin (Cuvitru®), 100 mg.
J1556	Injection, immune globulin (Bivigam®), 500 mg.
J1557	Injection, immune globulin (Gammaplex®), intravenous, non-lyophilized (e.g., liquid), 500 mg.
J1558	Injection, immune globulin (Xembify®), 100 mg.

1–10 of 14

1/2

Applicable procedure and drug codes (part 2)mixed

J1569	Injection, immune globulin (Gammagard® liquid), intravenous, nonlyophilized (e.g., liquid), 500 mg.
J1572	Injection, immune globulin (Flebogamma®/Flebogamma® DIF), intravenous, nonlyophilized (e.g., liquid), 500 mg.
J1575	Injection, immune globulin/hyaluronidase (HyQvia®), 100 mg immune globulin.
J1576	Injection, immune globulin (Panzyga), intravenous, non-lyophilized (e.g., liquid), 500 mg.
J1599	Injection, immune globulin, intravenous, nonlyophilized (e.g., liquid), not otherwise specified, 500 mg.

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required and will be determined using the current InterQual® criteria. Refer to the InterQual guideline for the specific product being requested (for example: Alyglo, Asceniv, Bivigam, Cutaquig, Cuvitru, Flebogamma DIF, Gammagard Liquid, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Hizentra, HyQvia, and others listed in the policy). In the absence of a product-specific InterQual rule, prescribing and dosing information from the manufacturer’s package insert and applicable drug policy criteria will be used to determine benefit coverage.

Prior authorization based on applicable InterQual criteria for the requested immune globulin product
If no InterQual product-specific guideline exists, clinical review will consider package insert dosing and applicable drug policy criteria

Denial Risk

Denial Risk — Medical Necessity

Services may be denied if documentation does not support medical necessity per InterQual criteria or applicable drug policy. Lack of required clinical information (diagnosis, prior treatment history, dosing rationale, or other supporting documentation) can result in denial for not medically necessary.

Denial risk when submitted documentation does not meet InterQual medical necessity criteria
Denial risk if required clinical history or dosing rationale is missing or incomplete

Documentation Required

Documentation and Governing References

Submit complete clinical documentation to support the request, including relevant diagnosis codes, clinical notes, prior therapies tried and failed (when applicable), and dosing calculations. UnitedHealthcare uses the InterQual® criteria and the drug policy (including applicable federal, state [OAC], and contractual requirements) as governing references when making coverage determinations. This policy is informational and does not replace plan-specific terms.

Include diagnosis and procedure codes relevant to the request
Provide clinical notes documenting indication, prior treatments, and rationale for product selection and dosing
Coverage determinations are governed by federal, state (OAC), or contractual requirements when they conflict with standard policy

Background

This policy addresses UnitedHealthcare coverage and medical necessity determinations for FDA‑approved intravenous (IV) and subcutaneous (SC) immune globulin products used to treat immunodeficiency and immune‑mediated conditions. Medical necessity for initial and ongoing use is determined using the current InterQual® guideline specific to the requested immune globulin product; when a product is not listed, the product package insert and InterQual guidance should be used to inform dosing and medical necessity decisions.

Definitions

InterQual® guideline — definition and role in determinations

DefinitionInterQual® guideline: a third-party clinical criteria set used by UnitedHealthcare to determine medical necessity for specific immune globulin products.

Role in determinationsMedical necessity and prior authorization decisions for listed IVIG and SCIG products are based on the current InterQual® guideline for the specific product requested.

Product mappingThe policy references product-specific InterQual® entries (for example: Alyglo, Asceniv, Bivigam, Cutaquig, Cuvitru, Flebogamma DIF, Gammagard Liquid) to evaluate requests.

When product not listedIf a product is not listed in the policy, prescribing and dosing information from the product package insert is used in addition to applicable policy criteria to determine benefit coverage.

Provider actionProviders should request coverage and supporting documentation consistent with the InterQual® criteria identified for the specific immune globulin product.