Superseded Local Coverage Article

Intravenous Immune Globulin (IVIg)-NCD 250.3


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Contractor Information

Article Information

General Information

Article ID
Article Title
Intravenous Immune Globulin (IVIg)-NCD 250.3
Article Type
Original Effective Date
Revision Effective Date
Revision Ending Date
Retirement Date
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Article Guidance

Article Text
This article describes CMS national coverage effective on/after October 1, 2001. Please see the Noridian Local Coverage Determination for additional indications.

Patient must meet at least one of the following criteria:

• Failed conventional therapy. Contractors have the discretion to define what constitutes failure of conventional therapy;
• Conventional therapy is contraindicated. Contractors have the discretion to define what constitutes contraindications to conventional therapy; or
• Have rapidly progressive disease in which a clinical response could not be affected quickly enough using conventional agents. In these situations, IVIg therapy would be give along with conventional treatment(s) and the IVIg would be used only until conventional therapy could take effect.

Note: In addition, IVIg for the treatment of autoimmune mucocutaneous blistering disease must be used only for short term therapy and not as a maintenance therapy. Again, contractors have the discretion to decide what constitutes short-term therapy.

Coding Information

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.


Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.




ICD-10-CM Codes that are Covered

Group 1

(14 Codes)
Group 1 Paragraph

The following diagnosis codes are appropriate. Intravenous immune globulin (IVIg) is covered nationally for the treatment of the following biopsy-proven conditions:

Group 1 Codes
L10.0 Pemphigus vulgaris
L10.1 Pemphigus vegetans
L10.2 Pemphigus foliaceous
L10.3 Brazilian pemphigus [fogo selvagem]
L10.4 Pemphigus erythematosus
L10.5 Drug-induced pemphigus
L10.81 Paraneoplastic pemphigus
L10.89 Other pemphigus
L10.9 Pemphigus, unspecified
L12.0 Bullous pemphigoid
L12.1 Cicatricial pemphigoid
L12.8 Other pemphigoid
L12.9 Pemphigoid, unspecified
L13.8 Other specified bullous disorders

ICD-10-CM Codes that are Not Covered


Revision History Information

Revision History DateRevision History NumberRevision History Explanation
11/07/2015 R1 Diagnosis L14 is deleted effective 5/20/2015 per CR 9252, dated 12/3/2015. The Part A article (A54642) is retired and Part A contract numbers are added to the Part B article.

Associated Documents

Related Local Coverage Documents
L34074 - Immune Globulin Intravenous (IVIg)
Statutory Requirements URLs
Rules and Regulations URLs
CMS Manual Explanations URLs
Other URLs
Public Versions
Updated On Effective Dates Status
05/07/2020 11/07/2015 - N/A Currently in Effect View
01/18/2017 11/07/2015 - N/A Superseded You are here
09/01/2015 11/07/2015 - N/A Superseded View


  • Intravenous
  • Immune
  • Globulin
  • IVIg