Medicare

    • Anonymous
      March 17, 2008 at 3:22 pm

      Questions regarding Medicare coverage come up on different threads, and it can be difficult to navigate through the many discussions to find an answer.

      This first post is intended as a partial guide through the national medicare system on some of the topics that frequently come up and will give everyone an opportunity to share their individual experiences at their local level. Newcomers can search or ask questions specific to their state here also.

      To search Medicare:

      http://www.cms.hhs.gov/mcd/search.asp?clickon=search
      enter keyword: ivig
      Remember to search in your state

      (The first time, you may be presented with a typical incoherent government document – scroll down to the bottom and accept – its a terms of service agreement.)

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      To find a list of Medicare Carriers for your state:

      http://www.cms.hhs.gov/mcd/index_lmrp_bystate.asp

      Note: different carriers may be approved for Part A, Part B, Home Health, and Durable Medical Equipment Coverage in your state

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      For CMS National Coverage Policy:
      http://www.cms.hhs.gov/Manuals/IOM/list.asp

      Medicare Benefit Policy Manual (Pub. 100-02)
      Chapter 1 – Inpatient Hospital Services
      Chapter 15- Covered Medical and Other Health Services

      Medicare Claims Processing Manual (Pub. 100-04)
      Chapter 17 – Drugs & Biologicals
      Payment Rules for Drugs and Biologicals
      80.3 – Billing for Immunosuppressive Drugs
      80.6 – Intravenous Immune Globulin

      Chapter 29 – Appeals of Claims Decision
      60.11 – Review – The First Level of Appeal
      60.11.1 – Filing a Request for Review
      60.11.2 – Time Limit for Filing a Request for Review

      Correct Coding Initiative (Pub. 100-09)
      guidelines for provider/carrier services

      Hint: to search within these documents (Ctrl +F), if ivig is not found, use the term biologicals

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      From Chapter 1, Inpatient Hospital Services:

      Drugs and biologicals for use in the hospital, which are ordinarily furnished by the hospital for the care and treatment of inpatients, are covered.

    • Anonymous
      March 17, 2008 at 3:24 pm

      The default Medicare carrier in Texas is Trailblazers. Here is their official position of ivig for the treatment of cidp as of 2/18/2008. Coverage is possible through inpatient, outpatient, home health care, physicial services, or rural health services – but they must be approved medicare providers (not all hospitals are, for example). In our experience, we found the hospital inpatient/outpatient the least hassle, and payment rates for the providers were greater than other venues.

      If your daily activities are seriously impaired, you will be covered – it takes good documentation and sometimes a letter from your doctor stating medical necessity.

      – article L17363

      Chronic Inflammatory Demyelinating Polyneuritis (CIDP)

      The diagnosis of this condition must be documented in the medical record and must be consistent with published diagnostic criteria for this condition.

      — The patient has unequivocal CIDP, as defined by the mandatory clinical and physiologic or pathologic criteria of the American Academy of Neurology (Neurology 41: pp. 617-618, 1991) or from the Medical Advisory Committee of the Neuropathy Association (J Peripheral Nervous Assn, 2003, 8:282-284).

      — The patient has proved refractory to, or intolerant of, prednisone or azathioprine given in therapeutic doses over at least three months.

      — The patient has a neurologic function assessment score of at least three or greater on the Rankin Scale at the time of initial therapy.

      IVIG will not be covered as an initial therapy for patients with newly diagnosed CIDP or as maintenance therapy in patients failing to respond to an initial course of IVIG following therapies with other agents. An exception to IVIG as an initial therapy would be in patients with severe CIDP (Rankin scores of 4 or 5) in whom a rapid therapeutic response is deemed medically desirable or in any patient meeting coverage criteria above (bullets one and three) for whom immunosuppressives are contraindicated. Patients responsive to an initial course of IVIG will be eligible for maintenance therapy coverage only if unequivocal neurological deterioration occurs at some future point in time.

    • jdme282@aol.com
      April 11, 2022 at 4:58 pm

      For an excellent 2022 guide to transitioning your IG coverage to Medicare, see. https://www.igliving.com/magazine/articles/IGL_2022-04_AR_Transitioning-Your-IG-Coverage-to-Medicare.pdf.

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