Effective February 1, 2010, Harvard Pilgrim will require prior authorization for intravenous immune globulin (IVIg) for members enrolled in Core HMO, PPO, and POS products. Harvard Pilgrim will reimburse for IVIg only when all of the following conditions are met:
- Its use is medically necessary and proven effective for patients with specific immunodeficiency conditions, diseases, and disorders.
- The dosage, frequency, site of administration, and duration of therapy are reasonable, clinically appropriate, and supported by evidence-based literature.
- Dosage, frequency, and duration of therapy are adjusted based upon severity, alternative available treatments, and previous response to IVIg therapy for the condition being addressed.
Initial authorization is limited to three months, unless otherwise specified. Authorization requests/transactions must contain an accurate diagnosis. Further IVIg therapy may be reauthorized only when all of the following conditions are met:
- The requested dosage and frequency is supported by evidence-based literature.
- The medical condition or disease under treatment has not fully resolved or exceeded Harvard Pilgrim's guidelines.
- There continues to be a sustained beneficial response to IVIg as evidenced by clinical documentation detailing progress to date, and the expected frequency and duration of any proposed IVIg use going forward.
IVIg services, when rendered by a physician, also require a PCP referral for HMO and in-network POS members.
IVIg claim submissions must contain the approved diagnosis. Harvard Pilgrim does not reimburse for IVIg when its use is unproven, or considered investigational for the individual's medical condition, disease, or disorder. To see a full list of covered and excluded conditions, go to Harvard Pilgrim’s IVIg Medical Review Criteria.