-
IVIG Getting Approval, Easy or Hard?
In the past couple of weeks, I’ve spoken with at least three people considering starting IVIG and wondering how, or if, it will be covered by insurance, or getting denied.
The literature is out there that IVIG immunoglobulin is effective in treating LEMS. There have been large studies on its efficacy with our sister disorder, MG. Because we’re so rare, large studies have not been done for LEMS.
Here’s one such paper in the National Institute of Health library, here.
Immunoglobulin therapy is expensive. I could cite the billing I see of my own service, but it may not be relevant in other cases. I think it safe to say one course of immunoglobulin can cost in the tens of thousands of dollars. I’m lucky the VA has covered my expense for IVIG with no co-pay, and I’m not aware my neurologist had any difficulty getting it started.
But I hear of other cases where insurance balks. I searched up a 39-page document from a large health insurance provider, to see what criteria they have for giving IVIG for LEMS. Read this list of items, and one can get a sense of their mindset:
Lambert-Eaton myasthenic syndrome (LEMS)
Additional information to support medical necessity review where applicable:
Immune globulin is medically necessary for the treatment of Lambert-Eaton myasthenic syndrome when all of the following criteria are met:
o Diagnosis of Lambert-Eaton myasthenic syndrome (LEMS); and
o History of failure, contraindication, or intolerance to immunomodulator monotherapy (e.g., azathioprine, corticosteroids); and
o Concomitant immunomodulator therapy (e.g., azathioprine, corticosteroids), unless contraindicated, will be used for long-term management of LEMS; and
o Prescribed by or in consultation with a neurologist; and
o IVIG dose does not exceed 2,000 mg/kg per month given over 2 to 5 consecutive days.
62 IVIG administration may be repeated monthly as needed to prevent exacerbation. Dosing interval may need to be adjusted in patients with severe comorbidities; and
o For long-term treatment, documentation of titration to the minimum dose and frequency is needed to maintain a sustained clinical effect.This is quite a list!
Have you been successful in getting IVIG coverage from your insurance? Have you been denied? And if you’ve been denied, were you able to appeal with success?
Log in to reply.