Page 82 - Medicare Benefit Policy Manual

50.6 – Coverage of Intravenous Immune Globulin for Treatment of
Primary Immune Deficiency Diseases in the Home
(Rev. 259, Issued: 07-12-19, Effective: 08-13-19, Implementation: 08-13-19)

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 provides
coverage of intravenous immune globulin (IVIG) for the treatment of primary immune
deficiency diseases in the home (ICD-9 diagnosis codes 279.04, 279.05, 279.06, 279.12,
and 279.2 or ICD-10-CM codes G11.3, D80.0, D80.2, D80.3, D80.4, D80.5, D80.6,
D80.7, D81.0, D81.1, D81.2, D81.5, D81.6, D81.7, D81.89, D81.9, D82.0, D82.1, D82.4,
D83.0, D83.1, D83.2, D83.8, or D83.9 if only an unspecified diagnosis is necessary). The
Act defines “intravenous immune globulin” as an approved pooled plasma derivative for
the treatment of primary immune deficiency disease. It is covered under this benefit
when the patient has a diagnosed primary immune deficiency disease, it is administered
in the home of a patient with a diagnosed primary immune deficiency disease, and the
physician determines that administration of the derivative in the patient’s home is
medically appropriate. The benefit does not include coverage for items or services
related to the administration of the derivative. For coverage of IVIG under this benefit, it
is not necessary for the derivative to be administered through a piece of durable medical
equipment.

60 - Services and Supplies Furnished Incident To a Physician’s/NPP’s
Professional Service
(Rev. 1, 10-01-03)
B3-2050

A - Noninstitutional Setting

For purposes of this section a noninstitutional setting means all settings other than a
hospital or skilled nursing facility

Medicare pays for services and supplies (including drug and biologicals which are not
usually self-administered) that are furnished incident to a physician’s or other
practitioner’s services, are commonly included in the physician’s or practitioner’s bills,
and for which payment is not made under a separate benefit category listed in §1861(s) of
the Act. A/B MACs (A) and (B) must not apply incident to requirements to services
having their own benefit category. Rather, these services should meet the requirements of
their own benefit category. For example, diagnostic tests are covered under §1861(s)(3)
of the Act and are subject to their own coverage requirements. Depending on the
particular tests, the supervision requirement for diagnostic tests or other services may be
more or less stringent than supervision requirements for services and supplies furnished
incident to physician’s or other practitioner’s services. Diagnostic tests need not also
meet the incident to requirement in this section. Likewise, pneumococcal, influenza, and
hepatitis B vaccines are covered under §1861(s)(10) of the Act and need not also meet
incident to requirements. (Physician assistants, nurse practitioners, clinical nurse
specialists, certified nurse midwives, clinical psychologists, clinical social workers,
physical therapists and occupational therapists all have their own benefit categories and