Immune Globulins for Post-Exposure Prophylaxis

Number: 0544

Policy

Hepatitis A Immune Globulin

Aetna considers hepatitis A immune globulin medically necessary for members who are exposed or likely to be exposed to hepatitis A virus (HAV).  Risk groups include household and sexual contacts of persons with hepatitis A, newborn infants of HAV-infected mothers, staffFootnotes* and children at child-care centers and schools with HAV outbreaks, staffFootnotes* of custodial care institutions with HAV outbreaks, and individuals exposed to HAV through food or waterborne outbreaks. 

Aetna considers hepatitis A immune globulin experimental and investigational for other indications because of insufficient evidence of safety and effectiveness.

Hepatitis B Immune Globulin

Aetna considers hepatitis B immune globulin medically necessary for members who have had contact with an individual diagnosed with hepatitis B virus (HBV).  Risk groups include infants born to hepatitis B surface antigen (HBsAg)-positive mothers, persons with percutaneous or permucosal exposure to HbsAg-positive blood, sexual contacts of HbsAg-positive persons, and household exposure of infants less than 1 year of age to a primary caregiver with acute HBV infection. 

Aetna considers prolonged use of hepatitis B immune globulin medically necessary for prophylaxis of recurrent hepatitis B infection in HbsAg-positive liver transplant recipients.  

Aetna considers hepatitis B immune globulin experimental and investigational for other indications (e.g., for use during pregnancy for prevention of mother-to-child transmission of hepatitis B virus) because of insufficient evidence of safety and effectiveness.

Cytomegalovirus Immune Globulin

Aetna considers cytomegalovirus (CMV) immune globulin (e.g., Cytogam) medically necessary for treatment of severe cytamegalovirus disease in transplant recipients, and for prophylaxis of CMV disease in CMV-negative renal transplant recipients receiving a CMV-positive donor organ, and for prophylaxis of CMV disease in lung, liver, pancreas, and heart transplant recipients  receiving a CMV-positive donor.

Aetna considers the use of CMV immune globulin experimental and investigational for all other indications, including use in prophylaxis in persons with IgA deficiency or Waldenstrom's macroglobulinemia, prevention of congenital cytomegalovirus, treatment of in-utero cytomegalovirus infection because of insufficient evidence of its safety and effectiveness.

See also CPB 0206 - Parenteral Immunoglobulins.

Rho-D Immune Globulin

Aetna considers Rho-D Immune Globulin (e.g., Gamulin Rh, HypRho-D Full Dose, HypRho-D Mini-Dose, MICRhoGAM, Mini-Gamulin Rh, Rhogam, and WinRho SDF) medically necessary for preventing hemolytic disease of the newborn.  Rho-D immune globulin is considered medically necessary for all unsensitized Rh-negative women at 24 to 28 weeks gestation, unless the father is known to be Rh-negative.  A repeat post-partum dose is considered medically necessary if a Rh-positive infant is delivered.  Administration of Rho-D immune globulin is considered medically necessary in unsensitized Rh-negative women, unless the father is known to be Rh-negative, after other obstetric complications such as amniocentesis, chorionic villus sampling, ectopic pregnancy, pregnancy termination (including elective abortion), cordocentesis, fetal surgery or manipulation (including external version), antepartum placental hemorrhage, ante-partum fetal death, miscarriage and stillbirth.  Rho-D immune globulin is also considered medically necessary for treatment of Rho-D positive persons with idiopathic thrombocytopenic purpura.

Aetna considers Rho-D immune globulin experimental and investigational for other indications because of insufficient evidence of its safety and effectiveness.

Rabies Immune Globulin

Aetna considers rabies immune globulin medically necessary for treatment of rabies exposure where the animal has escaped or is known to be rabid at the time of direct exposure or attackFootnotes*.  

Aetna considers rabies immune globulin experimental and investigational for other indications because of insufficient evidence of its safety and effectiveness.

Varicella Zoster (Chickenpox) Immune Globulin

Aetna considers varicella zoster immune globulin (VZIG) medically necessary for prevention of varicella (chickenpox) infections in high-risk individuals who have significant exposure to the disease due to contact with an individual who is infected with varicella, according to recommendations of the American Academy of Pediatrics.  High-risk individuals include immunocompromised persons without a history of chickenpox, susceptible pregnant women, newborn infants whose mother had onset of chickenpox within the 5 days before delivery or within 48 hours after delivery, hospitalized premature infants 28 or more weeks gestation whose mother has no history of chickenpox, and hospitalized premature infants less than 28 weeks gestation regardless of maternal history.  Significant exposures include household contacts of infected persons, face-to-face indoor play with infected persons, hospital contact with infected persons, and newborn infants whose mothers had onset of chickenpox near time of delivery (described above). 

Aetna considers post-exposure prophylaxis with varicella zoster immune globulin (VariZIG) as soon as possible within 10 days after exposure to a person with varicella or shingles medically necessary for HIV positive individuals who are susceptible to varicella zoster virus (those who have not been vaccinated, have no history of varicella or herpes zoster, or are seronegative for varicella zoster virus).

Aetna considers VZIG experimental and investigational for other indications because of insufficient evidence of its safety and effectiveness.

Tetanus Immune Globulin

Aetna considers intra-muscular injection of tetanus immune gamma globulin medically necessary for prevention of tetanus in non-immunized persons, incompletely immunized persons (who have not completed the 3-dose primary vaccination series), and remotely immunized persons (last complete vaccination more than 10 years ago) with neglected or tetanus-prone wounds (contaminated, necrotizing, or puncture wounds)Footnotes*.  

Aetna considers tetanus immune globulin experimental and investigational for other indications because of insufficient evidence of its safety and effectiveness.

Rubeola (Measles) Immune Globulin

Aetna considers intramuscular injection of measles (rubeola) immune globulin medically necessary for unvaccinated individuals exposed to the disease. 

Aetna considers rubeola immune globulin experimental and investigational for other indications because of insufficient evidence of its safety and effectiveness.

Immune Globulin (IVIG) for German Measles (Rubella)

Aetna considers non-specific intravenous immune globulin (IVIG) medically necessary for non-immune women with documented exposure to rubella during the first trimester (3 months) of pregnancy.  

Aetna considers IVIG for rubella experimental and investigational when these criteria are not met because of insufficient evidence of its safety and effectiveness.

Respiratory Syncytial Virus (RSV) Immune Globulin or Palivizumab

See CPB 0318 - Synagis (Palivizumab).

Vaccinia (Smallpox) Immune Globulin

Aetna considers vaccinia vaccine medically necessary for treatment of vaccine complications with severe clinical manifestations (e.g., eczema vaccinatum, progressive vaccinia, severe generalized vaccinia, and severe ocular viral implantation).Footnotes* 

Aetna considers vaccinia immune globulin experimental and investigational for other indications because of insufficient evidence of its safety and effectiveness.  See also CPB 0644 - Smallpox Vaccine.

Infantile Botulism Immune Globulin

Aetna considers human-derived botulinum immune globulin (BabyBIG or BIG-IV) for the treatment of infant botulism caused by toxin types A or B in members below 1 year of age medically necessary.

Aetna considers human-derived botulinum immune globulin (BabyBIG or BIG-IV) experimental and investigational for other indications because of insufficient evidence of its safety and effectiveness.

Immune Globulin IM (GamaSTAN S/D (formerly BayGam))

Aetna considers immune globulin IM (IGIM) medically necessary for the following indications

  • Hepatitis A. The prophylactic value of IGIM is greatest when given before or soon after exposure to hepatitis A. IGIM is considered experimental and investigational for individuals with clinical manifestations of hepatitis A or in those exposed more than 2 weeks previously; or
  • Measles (rubeola), for the prevention or modification of measles in susceptible contacts (one who has not been vaccinated and has not had measles previously) exposed less than 6 days previously. Note: IGIM should not be given with measles vaccine.
  • Immunoglobulin deficiency, to prevent serious infection if circulating IgG levels of approximately 200 mg/dL plasma are maintained; or
  • Varicella, prevention in immunosuppressed persons, if varicella zoster immune globulin is unavailable.. Note: Passive immunization against varicella in immunosuppressed persons is best accomplished with varicella-zoster immune globulin.

Aetna considers IGIM experimental and investigational for rubella prophylaxis. The routine use of IGIM for rubella prophylaxis in early pregnancy is of dubious value and cannot be justified. 

Footnotes* Note: Treatment of work-related injuries is excluded from coverage under some benefit plans.  Please check benefit plan descriptions.  Work-related injuries may be covered by the employer's workman's compensation benefit plan.

Background

Cytomegalovirus Immune Globulin

Cytogam (cytomegalovirus immune globulin, human) is a purified immune globulin, IgG, derived from pooled adult human serum selected for high titers of antibody to cytomegalovirus (CMV). The pooled plasma is fractionated to yield a product suitable for intravenous administration and further subjected to a solvent‐detergent viral inactivation process. The globulin is stabilized with 5% sucrose and 1% human albumin.

Cytomegalovirus Immune Globulin IV (CMV-Ig) contains antibodies directed specificially towards cytomegalovirus (CMV), which is generally present in persons who have been exposed to the virus.  While CMV is quite prevalent in adults and is typically benign in healthy people, it is a significant cause of morbidity and mortality in people who are immunosuppressed due to organ transplantation or AIDS. Cytomegalovirus immune globulin human can raise the serum titer of antibodies against CMV to sufficient levels to attenuate or reduce the occurrence of serious CMV infection.

Cytomegalovirus Immune Globulin IV is currently approved by the Food and Drug Administration (FDA) for use in prophylaxis of CMV disease in kidney, heart, lung, pancreas and liver transplant patients.  It also has been shown to be beneficial in prevention and treatment of CMV disease in patients who have received an orthotopic liver transplant.  There is also evidence for use of CMV-Ig in other solid organ transplants (such as heart and lung) and in bone marrow transplants.

Studies in renal transplantation have generally been limited to patients who are CMV sero-negative; use in sero-positive recipients therefore remains investigational.  This is not the case with other transplants; in fact, results in liver transplant patients have shown a decrease in severe CMV-associated syndromes.

CMV is the primary viral pathogen that will be encountered by members who receive kidney, liver, pancreas, lung, and heart transplants. CMV is associated with increases in morbidity, including fever, leukopenia, hepatitis, pneumonia, and CMV retinitis. Administration of cytomegalovirus immunoglobulin has been associated with a significant decrease in CMV‐related morbidity from 60% to 21% in renal transplant recipients. Similar findings have been reported in liver transplant recipients with the incidence of serious CMV disease significantly decreasing from 26% to 12%.

It has been reported that combination prophylaxis with ganciclovir has produced results demonstrating much lower incidence of CMV infection than either drug alone. Specifically, in liver transplant patients combination with ganciclovir significantly decreased the incidence of severe CMV infection from 28% to 5% when compared to monotherapy with CMV immune globulin. Rates of serious CMV infection of 1%, 0%, and 8% were demonstrated with combination therapy in kidney, kidney‐pancreas, and liver transplant recipients, respectively. In heart, heart‐lung, and lung transplant recipients, incidence rates decreased significantly when cytomegalovirus immune globulin was added to ganciclovir prophylaxis and overall survival rates increased significantly.

Members with a history of severe reactions to cytomegalovirus immune globulin or other human immunoglobulin preparations should not receive Cytogam.

Dosage Adjustments:

No recommendations for dosage adjustments

Test/Lab Justifications:

  • Anti‐neutrophil antibodies if Transfusion‐related Acute Lung Injury suspected
  • Blood viscosity testing for members at high risk of thrombosis (cryoglobulins, fasting chylomicronemia/markedly high triglycerides, or monoclonal gammopathies)
  • Hemolysis testing if hemolysis is suspected

In a retrospective analysis, Buxmann et al (2012) examined the current prenatal "off-label use" of CMV-hyperimmune globulin (CMV-HIG) in the prevention and treatment of congenital CMV (cCMV) infection, including the long-term outcome of the children.  This retrospective observational study comprised mothers and their children, born between January 1, 2006, and October 30, 2010.  Prenatal CMV-HIG was administered after diagnosis of primary CMV infection of the mother.  Clinical and virological data were collected from maternal and pediatric medical and laboratory reports.  Follow-up was 12 to 36 months after birth.  A total of 42 women and 43 children met the study criteria.  In total, 40 mothers and 6 unborn infants received 115 doses of CMV-HIG.  The treatment group (TG; CMV-DNA polymerase chain reaction-positive amniotic fluid) included 4 mothers; the multi-nomial group (MG; CMV-positive mother and unknown CMV status of fetus) included 38 mothers (39 infants).  For the 4 unborn infants in TG, CMV-HIG was administered either intra-umbilically or into the amniotic fluid; 3 of the 4 mothers received intravenous CMV-HIG.  Three children in TG remained CMV-positive and were asymptomatic at birth and during follow-up.  One infant in TG had symptomatic cCMV infection in-utero, at birth, and during follow-up.  In MG, 37 of 38 women received intravenous CMV-HIG and 2 of 39 infants received CMV-HIG in-utero.  In total, 9 (23.1 %) of 39 children in MG were positive for cCMV (including a terminated pregnancy).  All 8 instances of cCMV infection at birth in MG were asymptomatic at birth and during follow-up.  The fetus from the terminated pregnancy showed no sonographic symptoms of cCMV infection.  No severe side effect occurred in 115 CMV-HIG applications.  The authors concluded that CMV-HIG was well-tolerated.  Compared with published untreated mother-child pairs, the authors observed a trend toward a smaller risk for intrauterine CMV transmission following CMV-HIG application.  Signs of prenatal cCMV disease were not reversed after CMV-HIG.

Simioni et al (2013) stated that primary CMV infection during pregnancy is the leading infectious cause of congenital neurological disabilities.  Diagnosis of maternal primary CMV infection and fetal compromise can be difficult, as well as the fact that most infected child are asymptomatic at birth, which makes binomial CMV and pregnancy challenging.  The treatment of pregnant women with CMV-HIG has shown promising results.  However, as far as the authors knew, no randomized trials of immunoglobulin therapy of CMV-infected fetuses are ongoing. 

An UpToDate review on “Cytomegalovirus infection in pregnancy” (Sheffield and Boppana, 2013) states that “Hyperimmunoglobulin therapy of pregnant women with primary CMV infection in early pregnancy is a promising, but investigational, approach to reducing symptomatic infection in offspring.  Data are limited to the following studies …. There are several limitations to interpreting these data.  These include the lack of randomization, the absence of a control group that received placebo, the use of historic controls, a small number of adverse events, and use of interventions that differed in the therapy and prevention groups and in cases and controls.  None of the studies addressed the financial and logistical issues associated with screening large obstetrical populations for CMV infection and the expense of pursuing false positive results.  Until data from randomized trials are available, practitioners should emphasize the simple preventive measures noted below (see 'Prevention' below and 'Precautions to prevent transmission' below).  Although hyperimmunoglobulin therapy is not generally recommended, the use of this therapy should be individualized.  Some pregnant women with primary CMV infection may choose to undergo this therapy after a discussion of the available data on the efficacy of hyperimmunoglobulin and the limitations of the few published studies, as well as potential side effects of this therapy.  It is currently being evaluated in a large multicenter National Institutes of Health (NICHD) trial and the results of this trial will better guide recommendations.  A second randomized European trial has just been completed and final data are being analyzed”.

In a phase II, randomized, placebo-controlled, double-blind study, Revello et al (2014) evaluated the effectiveness of hyperimmune globulin in the prevention of congenital cytomegalovirus.  A total of 124 pregnant women with primary CMV infection at 5 to 26 weeks of gestation were randomly assigned within 6 weeks after the presumed onset of infection to receive hyperimmune globulin or placebo every 4 weeks until 36 weeks of gestation or until detection of CMV in amniotic fluid.  The primary end- point was congenital infection diagnosed at birth or by means of amniocentesis.  A total of 123 women could be evaluated in the effectiveness analysis (1 woman in the placebo group withdrew).  The rate of congenital infection was 30 % (18 fetuses or infants of 61 women) in the hyperimmune globulin group and 44 % (27 fetuses or infants of 62 women) in the placebo group (a difference of 14 percentage points; 95 % confidence interval [CI]: -3 to 31; p = 0.13).  There was no significant difference between the 2 groups or, within each group, between the women who transmitted the virus and those who did not, with respect to levels of virus-specific antibodies, T-cell-mediated immune response, or viral DNA in the blood.  The clinical outcome of congenital infection at birth was similar in the 2 groups.  The number of obstetrical adverse events was higher in the hyperimmune globulin group than in the placebo group (13 % versus 2 %).  The authors concluded that in this study involving 123 women who could be evaluated, treatment with hyperimmune globulin did not significantly modify the course of primary CMV infection during pregnancy.  Moreover, they stated that “From the cost-effectiveness point of view, our results (a 32 % relative decrease in the transmission rate and no significant difference in the clinical outcome at birth) represent less than the 47 % reduction in congenital CMV that has been considered by some to be the threshold for recommending screening for and treatment of primary maternal infection in pregnancy as a cost-effective strategy.  Currently, two randomized, phase 3 studies of the prevention of congenital infection are under way.  One, sponsored by Biotest, is being conducted in Europe, and the second, sponsored by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, is ongoing in the United States (ClinicalTrials.gov number, NCT01376778).  The hope is that the results of these studies will further our understanding of the efficacy and safety of hyperimmune globulin administration as a means of preventing congenital CMV infection”.

Cytomegalovirus immune globulin, human is available as Cytogam in 2500 mg ± 500 mg per 50 mL (50 ± 10 mg/mL) vials.

Dosing:

  • Cytomegalovirus infection; Prophylaxis ‐ Transplant of heart, liver, pancreas, lung: 150 mg/kg IV within 72 hours of transplant and on weeks 2,4,6, and 8 post transplant and 100 mg/kg on weeks 12 and 16 post transplant
  • Cytomegalovirus infection; Prophylaxis ‐ Transplant of kidney: 150 mg/kg IV for 1 dose within 72 hours of transplant then 100 mg/kg on weeks 2,4,6, and 8 post transplant and 50 mg/kg on weeks 12 and 16 post transplant.

Hepatitis B Immune Globulin

Hepatitis B immune globulin is appropriate when used to provide passive immunization to hepatitis B as prophylaxis for certain exposed individuals.  The Advisory Committee on Immunization Practices (ACIP) states that combined passive and active immunization is preferred to passive immunization with HBIg alone in neonates born to HBsAb-positive women, in individuals exposed percutaneously or by ingestion or mucous membrane contact, and in individuals bitten by human carriers of HBsAG.  Also, combined treatment is recommended for patients exposed through sexual contact.  Hepatitis B immune globulin is administered promptly after exposure and again in 1 month.

Hepatitis B immune globulin is also indicated for prophylaxis of recurrent hepatitis B infection in HbsAg-positive liver transplant recipients.  Hepatitis B immune globulin prophylaxis is administered on a lifelong or indefinite basis for this indication.

The manufacturers state that the intra-muscular (IM) product is not to be used in an intravenous (IV0 fashion.  This is apparently because "serious systemic allergic reactions could occur following inadvertent IV administration of HBIg, since such reactions have occurred following IV administration of immune globulin".  Since it appears that the contraindication to IV use is theoretical, and that IV use is occurring without safety problems, it is appropriate to allow IV use when IM is not an option.

Rao and colleagues (2009) performed a systematic review and a meta-analysis to evaluate lamivudine monotherapy and combined therapy of lamivudine and hepatitis B immunoglobulin (HBIG) in hepatitis B virus (HBV) infected liver recipients.  A fixed effects model was used for statistical pooling of relative risks (RR) for the different outcomes.  Six articles (n = 551) fulfilled the inclusion criteria.  Statistically significant differences were observed between lamivudine monotherapy and lamivudine + HBIG therapy in hepatitis B recurrence (p < 0.0001; RR = 0.38; 95 % CI: 0.25 to 0.58), YMDD mutant (p = 0.002; RR = 0.40; 95 % CI: 0.23 to 0.72) and hepatitis B recurrence in HBV-DNA positive patients before orthotopic liver transplantation (p < 0.00001; RR = 0.31; 95 % CI: 0.21 to 0.45).  No significant differences were observed in patient survival (p = 0.59; RR = 1.02; 95 % CI: 0.95 to 1.09), graft survival (p = 0.56; RR = 1.02; 95 % CI: 0.95 to 1.09) and diseases leading to death between the 2 groups (HBV recurrence leading to death: p = 0.05; RR = 0.47; 95 % CI: 0.22 to 1.02); hepatocellular carcinoma recurrence leading to death: p = 0.13; RR = 0.34; 95 % CI: 0.09 to 1.36).  The authors concluded that combination of lamivudine and HBIG can effectively decrease the recurrence rate of HBV and the incidence of YMDD mutant, but it can not improve patient survival and graft survival significantly.  They stated that well-designed, large-sample trials are needed to evaluate the efficiency of combined therapy of lamivudine and HBIG in prophylaxis of HBV recurrence in liver graft recipients.

For Use During Pregnancy for Prevention of Mother-to-Child Transmission of Hepatitis B Virus

Eke and colleagues (2017) stated that hepatitis is a viral infection of the liver.  It is mainly transmitted between people through contact with infected blood, frequently from mother to baby in-utero.  Hepatitis B poses significant risk to the fetus and up to 85 % of infants infected by their mothers at birth develop chronic HBV infection; HBIG is a purified solution of human immunoglobulin that could be administered to the mother, newborn, or both; HBIG offers protection against HBV infection when administered to pregnant women who test positive for hepatitis B envelope antigen (HBeAg) or hepatitis B surface antigen (HBsAg), or both.  When HBIG is administered to pregnant women, the antibodies passively diffuse across the placenta to the child.  This materno-fetal diffusion is maximal during the 3rd trimester of pregnancy.  Up to 1 % to 9 % infants born to HBV-carrying mothers still have HBV infection despite the newborn receiving HBIG plus active HBV vaccine in the immediate neonatal period.  This suggests that additional intervention such as HBIG administration to the mother during the antenatal period could be beneficial to reduce the transmission rate in utero.  In a Cochrane review, these researchers determined the benefits and harms of HBIG administration to pregnant women during their 3rd trimester of pregnancy for the prevention of mother-to-child transmission (MTCT) of HBV infection.  They searched the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, Medline Ovid, Embase Ovid, Science Citation Index Expanded (Web of Science), SCOPUS, African Journals OnLine, and INDEX MEDICUS up to June 2016.  They searched ClinicalTrials.gov and portal of the WHO International Clinical Trials Registry Platform (ICTRP) in December 2016.  These researchers included randomized clinical trials comparing HBIG versus placebo or no intervention in pregnant women with HBV.  Two authors extracted data independently.  They analyzed dichotomous outcome data using risk ratio (RR) and continuous outcome data using mean difference (MD) with 95 % CI.  For meta-analyses, these investigators used a fixed-effect model and a random-effects model, along with an assessment of heterogeneity.  If there were statistically significant discrepancies in the results, they reported the more conservative point estimate.  If the 2 estimates were equal, these researchers used the estimate with the widest CI as their main result.  They assessed bias control using the Cochrane Hepato-Biliary Group suggested bias risk domains and risk of random errors using Trial Sequential Analysis (TSA); and assessed the quality of the evidence using GRADE.  All 36 included trials originated from China and were at overall high risk of bias.  The trials included 6,044 pregnant women who were HBsAg, HBeAg, or HBV-DNA positive.  Only 7 trials reported inclusion of HBeAg-positive mothers.  All 36 trials compared HBIG versus no intervention.  None of the trials used placebo.  Most of the trials assessed HBIG 100 IU (2 trials) and HBIG 200 IU (31 trials).  The timing of administration of HBIG varied; 30 trials administered 3 doses of HBIG 200 IU at 28, 32, and 36 weeks of pregnancy.  None of the trials reported all-cause mortality or other serious adverse events (AEs) in the mothers or babies.  Serological signs of hepatitis B infection of the newborns were reported as HBsAg, HBeAg, and HBV-DNA positive results at end of follow-up; 29 trials reported HBsAg status in newborns (median of 1.2 months of follow-up after birth; range 0 to 12 months); 7 trials reported HBeAg status (median of 1.1 months of follow-up after birth; range 0 to 12 months); and 16 trials reported HBV-DNA status (median of 1.2 months of follow-up; range 0 to 12 months); HBIG reduced MTCT of HBsAg when compared with no intervention (179/2,769 (6 %) with HBIG versus 537/2,541 (21 %) with no intervention; RR 0.30, TSA-adjusted CI: 0.20 to 0.52; I2 = 36 %; 29 trials; 5,310 participants; very low quality evidence); HBV-DNA reduced MTCT of HBsAg (104/1,112 (9 %) with HBV-DNA versus 382/1,018 (38 %) with no intervention; RR 0.25, TSA-adjusted CI: 0.22 to 0.27; I2 = 84 %; 16 trials; 2,130 participants; low quality evidence); TSA supported both results.  Meta-analysis showed that maternal HBIG did not decrease HBeAg in newborns compared with no intervention (184/889 (21 %) with HBIG versus 232/875 (27 %) with no intervention; RR 0.68, TSA-adjusted CI: 0.04 to 6.37; I2 = 90 %; 7 trials; 1,764 participants; very low quality evidence); TSA could neither support nor refute this observation as data were too sparse.  None of the trials reported AEs of the immunoglobulins on the newborns, presence of local and systemic AEs on the mothers, or cost-effectiveness of treatment.  The authors concluded that due to very low to low quality evidence found in this review, they are uncertain of the effect of benefit of antenatal HBIG administration to the HBV-infected mothers on newborn outcomes, such as HBsAg, HBV-DNA, and HBeAg compared with no intervention.  They stated that the results of the effects of HBIG on HBsAg and HBeAg are surrogate outcomes (raising risk of indirectness), and one need to be critical while interpreting the findings.  These investigators found no data on newborn mortality or maternal mortality or both, or other serious AEs.  They stated that well-designed randomized clinical trials are needed to determine the benefits and harms of HBIG versus placebo in prevention of MTCT of HBV.

Furthermore, an UpToDate review on “Hepatitis B and pregnancy” (Lee and Lok, 2017) does not mention the use of HBIG during pregnancy as a management tool.

Hepatitis A Immune Globulin

Hepatitis A immune globulin is indicated for persons who are exposed or likely to be exposed to hepatitis A virus (HAV).  Risk groups include household and sexual contacts of persons with hepatitis A, newborn infants of HAV-infected mothers, staff and children at child-care centers and schools with HAV outbreaks, staff of custodial care institutions with HAV outbreaks, and individuals exposed to HAV through food or water-borne outbreaks.  The usual dose is a single IM injection administered within 2 weeks of exposure.

Rho-D Immune Globulin

Rhogam is a specially prepared immune globulin injected into an Rh-negative mother to prevent Rh hemolytic disease in future children.  Rho-D immune globulin may be indicated for prevention of Rh hemolytic disease in neonates by administration to selected pre-menopausal, Rho-D-negative females; and for treatment of selected Rho-D-positive patients with ITP.

Administration of Rhogam is recommended under generally accepted guidelines for all unsensitized Rh-negative women at 24 to 28 weeks gestation, unless the father is known to be Rh-negative.  If a Rh-positive infant is delivered, accepted guidelines indicate the dose should be repeated post-partum, preferably within 72 hours of delivery.  The American College of Obstetricians and Gynecologists recommends administration of Rhogam after other obstetric complications such as amniocentesis, chorionic villus sampling, ectopic pregnancy, pregnancy termination, cordocentesis, fetal surgery or manipulation (including external version), ante-partum placental hemorrhage, ante-partum fetal death, miscarriage and stillbirth.  The literature indicates this immune globulin may also be used for treatment of selected Rho-D-positive persons with idiopathic thrombocytopenic purpura.  Under generally accepted guidelines, Rhogam is recommended for all unsensitized Rh-negative women after elective abortion, unless the father is known to be Rh-negative.

WinRho may be administered intramuscularly or intravenously over 3 to 5 mins.  Other brands are indicated for IM use.  Intramuscular injection is a relative contraindication in patients with ITP; however, has been used with some success.  While some feel that use of this product for treatment of ITP may not be effective in splenectomized patients, others provide evidence to the contrary.  When given in conjunction with pregnancy, Rho-D immune globulin does not provide benefit for the infant from that pregnancy.  Its use is intended to prevent Rh hemolytic disease in future infants born to that mother.

Varicella Zoster Immune Globulin

Varizig (varicella zoster immune globulin) is a solvent/detergent‐treated sterile lyophilized preparation of purified human immune globulin G (IgG) containing antibodies to varicella zoster virus (anti-VZV). Varizig (varicella zoster immune globulin) provides passive immunization for nonimmune individuals exposed to VZV, reducing the severity of varicella infections.

Varicella zoster virus (VZV) causes chickenpox in children and shingles in adults. Varizig is the only FDA approved immune globulin for VZV after exposure available in the United States. It was designated as an orphan drug by the FDA and received a priority review.

Varicella zoster immune globulin (VZIG) is considered appropriate when used to prevent varicella (chickenpox) infection as recommended by the ACIP.  According to the ACIP, VZIG is necessary, provided that significant exposure has occurred for immunocompromised children without a history of chickenpox.  Immuocompromised adolescents and adults are likely to be immune, but if susceptible, should also receive VZIG.  Varicella zoster immune globulin is also necessary, provided that significant exposure has occurred, for the following groups; susceptible pregnant women; newborn infants whose mother had onset of chickenpox within the 5 days before delivery or within the 48 hours after delivery; hospitalized premature infants (greater than or equal to 28 weeks gestation) whose mother has no history of chickenpox; and hospitalized premature infants (less than 28 weeks of gestation or less than or equal to 1,000 grams) regardless of maternal history.

Varicella zoster immune globulin may be indicated in the above listed susceptible groups if significant exposure to varicella has occurred in the hospital: in the same 2- to 4-bed room, or adjacent beds in a large ward; face-to-face contact with an infectious staff memeber or patient, or visit by a person deemed contageous.  Experts differ in the duration of face-to-face contact that warrants the administration of VZIG.  Some experts suggest a contact of 5 or more mins as constituting significant exposure for this purpose; others define close contact as more than 1 hour.  In any case, the face-to-face contact should be non-transient to be considered significant.

Other types of exposure for which VZIG is indicated in the above listed susceptible groups include: household exposure (residing in the same household); exposure from playmates (face-to-face indoor play); and intimate contact with zoster lesions (e.g., touching or hugging a person deemed contageous; and exposure of newborn infant (onset of varicella in the mother 5 days or less before delivery or within 48 hours after delivery; VZIG is not indicated if the mother has zoster).  The ACIP recommends that VZIG be administered within 96 hours of exposure

Laboratory determination of susceptibility to varicella is sometimes impractical.  Because of this, the ACIP recommends that determination of susceptibility be based on a carefully obtained history of prior infection or exposure.  However, in the case of pregnant women, serologic status should be determined through immunofluorescent assay or ELISA test if results can be available within 96 hours of exposure.  If this test is feasible and negative, immune globulin need not be given.  Otherwise, pregnant women should be considered susceptible.

Varicella zoster immune globulin is not necessary in individuals who are considered to be immune to varicella zoster.  With the exception of bone marrow transplant recipients, individuals considered to be immune to varicella zoster include those with a history of prior varicella infection, or negative or uncertain exposure if they are at least 15 years of age and immunocompetent.  In addition, patients with a history of infection with varicella or herpes zoster subsequent to bone marrow transplant are considered to be immune.

There is currently no evidence that administration of VZIG to pregnant women during the first or second trimester of pregnancy will prevent congenital varicella syndrome or that administration during the third trimester will prevent neonatal varicella.  In addition, post-exposure administration of VZIG in susceptible, pregnant women may prevent or suppress clinical disease in the mother without preventing fetal infection or disease.  For this reason, administration of VZIG for pregnant women who do not fit the criteria listed above is not considered to be necessary.

VariZIG (Cangene Corporation, Winnipeg, Canada) is the only VZIG preparation available in the United States for post-exposure prophylaxis of varicella in persons at high-risk for severe disease who lack evidence of immunity to varicella and are ineligible for varicella vaccine.  VariZIG is available in the United States through an investigational new drug (IND) application expanded access protocol.  It is a purified immune globulin preparation made from human plasma containing high levels of anti-varicella zoster virus antibodies (immunoglobulin G).  In May 2011, the FDA approved an extended period for administering VariZIG.  The period after exposure to varicella zoster virus during which a patient may receive VariZIG, which had been 96 hours (4 days), is now 10 days.  VariZIG should be administered as soon as possible after exposure (CDC, 2012).

Varicella zoster immune globulin is available as

  • Varizig in a single‐use vial of 125 IU Lyophilized Powder for Solution for Injection. Varizig is accompanied by a vial of 8.5 mL of sterile diluent used for reconstitution. Each vial of Varizig is reconstituted with 1.25 mL of sterile diluent.
  • Varizig Sterile Solution for Injection. Varizig is supplied as a sterile solution for intramuscular injection and is available in a single‐use vial of 125 IU in 1.2 mL.

Varizig (varicella zoster immune globulin) is administered as an intramuscular injection. The minimum dose of Varizig is 62.5 IU (1 vial) for small infants under two kilograms body weight. The maximum dose of 625 IU (5 vials) should be administered for all patients greater than 40 kilograms in weight. Consider a second full dose of Varizig for high risk patients who have additional exposures to varicella greater than three weeks after initial Varizig administration.

Varizig administration is intended to reduce the severity of varicella. Administer Varizig as soon as possible following varicella zoster virus (VZV) exposure, ideally within 96 hours for greatest effectiveness. There is no convincing evidence that Varizig reduces the incidence of chickenpox infection after exposure to VZV. There is no convincing evidence that established infections with VZV can be modified by Varizig administration. There is no indication for the prophylactic use of Varizig in immunodeficient children or adults when there is a past history of varicella, unless the patient is undergoing bone marrow transplantation.

Contraindications

  • Individuals known to have anaphylactic or severe systemic (hypersensitivity) reactions to human immune globulin preparations should not receive Varizig.
  • IgA-deficient patients with antibodies against IgA and a history of hypersensitivity may have an anaphylactoid reaction. Varizig contains less than 40 micrograms per milliliter of IgA.

Dosage and Administration

Table: Dosage and Administration
Weight of Patient (Kilograms)   Weight of Patient (Pounds) Varizig Dose (IU)   Volume to Administer** (milliliters) Number of Vials 
≤ 2.0   ≤ 4.4  62.5  0.5   0.6
2.1 - 10.0   4.5 - 22.0  125   1   1.2
10.1 - 20.0    22.1 - 44.0   250  2  2.4
20.1 - 30.0   44.1 - 66.0   375  3   3.6
30.1 - 40.0   0 66.1 - 88.0  500  4   4.8

≥ 40.1

 ≥ 88.1  625  5  6.0

Aberg et al (2014) reported on the 2013 update on primary care guidelines for management of HIV infected persons by the HIV Medicine Association of the Infectious Diseases Society of America.  New information based on literature published from 2009 to 2013 was incorporated into this updated version of the guidelines.  The guidelines make a strong recommendation, based on moderate quality evidence, that HIV positive patients who have not been vaccinated, have no history of varicella or herpes zoster, or are sero-negative for varicella zoster virus, and are thus susceptible to varicella zoster virus should receive post-exposure prophylaxis.  The post-exposure prophylaxis should consist of varicella zoster immune globulin (VariZIG) as soon as possible 9but within 10 days) after exposure to a person with varicella or shingles.  The recommendations further noted that varicella primary vaccination may be considered in HIV-infected, varicella zoster virus seronegative persons aged > 8 years with CD4 cell coungs > 200 cells / microliter and in HIV-infected children aged 1 to 8 years with CD4 cell percentages > 15% due to moderate quality evidence in the peer-reviewed literature.

Vaccinia (Smallpox) Immune Globulin

Vaccinia vaccine is indicated for treatment of vaccine complications with severe clinical manifestations (e.g., eczema vaccinatum, progressive vaccinia, severe generalized vaccinia, and severe ocular viral implantation).  The only product currently available for treatment of complications of vaccinia vaccination is vaccinia immunoglobulin, which is an isotonic sterile solution of the immunoglobulin fraction of plasma from persons vaccinated with vaccinia vaccine.  It is effective for treatment of eczema vaccinatum and certain cases of progressive vaccinia; it might be useful also in the treatment of ocular vaccinia resulting from inadvertent implantation.  However, vaccinia immunoglobulin is contraindicated for the treatment of vaccinial keratitis.  Vaccinia immunoglobulin is recommended for severe generalized vaccinia if the individual is extremely ill or has a serious underlying disease.  Vaccinia immunoglobulin provides no benefit in the treatment of post-vaccinial encephalitis and has no role in the treatment of smallpox.  The Centers for Disease Control and Prevention (CDC) (2001) states that current supplies of vaccinia immunoglobulin are limited, and its use should be reserved for treatment of vaccine complications with serious clinical manifestations.  According to the CDC (2001), vaccinia immunoglobulin should be administered as early as possible after the onset of symptoms.  Doses can be repeated, usually at intervals of 2 to 3 days, until recovery begins (e.g., no new lesions appear).  The CDC is currently the only source of vaccinia immunoglobulin for civilians.

Rabies Immue Globulin

Rabies immune globulin is indicated for treatment of rabies exposure where the animal has escaped or is known to be rabid at the time of direct exposure or attack.  Treatment of rabies exposure is comprised of a series of rabies vaccine (human diploid cell vaccine, HDCV) and a single rabies immune globulin injection (Rabies Immune Globulin, RIG).  For persons not previously vaccinated with HDCV, the usual frequency is a single IM injection of RIG and a series of HDCV consisting of 1-ml IM injection in the deltoid area on days 0, 3, 7, and 14.  For persons previously vaccinated with HDCV, 2 HDCV IM injections are given on days 0 and 3.  The literature indicates rabies immune globulin should not be administered to previously vaccinated individuals.

Tetanus Immune Globulin

Intramuscular injection of tetanus immune gamma globulin are indicated for prevention of tetanus in immunized or non-immunized persons for neglected or tetanus-prone wounds (contaminated, necrotizing, or puncture wounds).  Post-exposure prophylaxis with tetanus toxoid is recommended under accepted guidelines for wounded persons who have not completed the 3-dose primary vaccination series, and those who have completed vaccination more than 10 years ago.  In addition, accepted guidelines state incompletely vaccinated persons with serious or contaminated wounds should receive human tetanus immune globulin.  The usual dose is a single IM injection repeated at 4-week intervals, if necessary.

Rubeola (Measles) Immune Globulin

Intramuscular injection of measles (rubeola) immune globulin is indicated for unvaccinated individuals exposed to the disease.  Accepted guidelines recommend that the immune globulin should be administered within 6 days of exposure.

Immune Globulin for Rubella (German Measles)

The use of immune globulin for pregnant women with acute infection is controversial.  There are no data to suggest that immune globulin will have any beneficial effect on the fetal response to disease.  Thus, the CDC recommends limiting the use of immune globulin to women with known rubella exposure who decline pregnancy termination.  The usual dose of immune globulin is a single IM injection.

Infantile Botulism Immune Globulin

Arnon et al (2006) created the orphan drug Human Botulism Immune Globulin Intravenous (Human) (BIG-IV), which neutralizes botulinum toxin, and evaluated its safety and efficacy in treating infant botulism, the intestinal-toxemia form of human botulism.  These investigators performed a 5-year, randomized, double-blind, placebo-controlled trial statewide, in California, of BIG-IV in 122 infants with suspected (and subsequently laboratory-confirmed) infant botulism (75 caused by type A Clostridium botulinum toxin, and 47 by type B toxin); treatment was given within 3 days after hospital admission.  These researchers subsequently performed a 6-year nationwide, open-label study of 382 laboratory-confirmed cases of infant botulism treated within 18 days after hospital admission.  As compared with the control group in the randomized trial, infants treated with BIG-IV had a reduction in the mean length of the hospital stay, the primary efficacy outcome measure, from 5.7 weeks to 2.6 weeks (p < 0.001).  BIG-IV treatment also reduced the mean duration of intensive care by 3.2 weeks (p < 0.001), the mean duration of mechanical ventilation by 2.6 weeks (p = 0.01), the mean duration of tube or intravenous feeding by 6.4 weeks (p < 0.001), and the mean hospital charges per patient by 88,600 dollars (in 2004 U.S. dollars; p < 0.001).  There were no serious adverse events attributable to BIG-IV.  In the open-label study, infants treated with BIG-IV within 7 days of admission had a mean length of hospital stay of 2.2 weeks, and early treatment with BIG-IV shortened the mean length of stay significantly more than did later treatment.  The authors concluded that prompt treatment of infant botulism type A or type B with BIG-IV was safe and effective in shortening the length and cost of the hospital stay and the severity of illness.

Underwood et al (2007) reported a tertiary care hospital's 30-year experience with the diagnosis, treatment, and outcome of infant botulism in the PICU before and after the availability of Botulism Immune Globulin Intravenous.  This was a retrospective medical chart review of the 67 patients who had received a diagnosis of infant botulism and were admitted to the ICU from 1976 to 2005.  The ages on presentation, length of hospital stay, length of ICU stay, length of mechanical ventilation, and type of botulism toxin were recorded and compared for patients who had received Botulism Immune Globulin Intravenous and those who had not.  On the basis of these results, conclusions were drawn regarding the effect of Botulism Immune Globulin Intravenous on the morbidity of infant botulism.  A total of 67 patients' charts were reviewed; 23 male and 29 female patients did not receive Botulism Immune Globulin Intravenous.  Of patients who did not receive Botulism Immune Globulin Intravenous, the median age at presentation was 71 days, median length of hospital stay was 35 days, ICU stay was 24 days, and duration of mechanical ventilation was 17 days.  A total of 40 % had type A toxin, and 60 % had type B toxin.  There was a significant difference between patients with toxin types A and B in length of hospital stay but not length of ICU stay or mechanical ventilation.  Patients with type A toxin were significantly older than patients with type B toxin.  Fifteen children received Botulism Immune Globulin Intravenous.  There were statistically significant differences in length of hospital stay, length of ICU stay, and length of mechanical ventilation between patients who received Botulism Immune Globulin Intravenous and those who did not.  The authors concluded that the use of Botulism Immune Globulin Intravenous significantly decreased the length of ICU stay, length of mechanical ventilation, and overall hospital stay in children with infant botulism.

Vanella de Cuetos et al (2011) stated that infant botulism is the most common form of human botulism in Argentina and the United States.  BabyBIG (botulism immune globulin intravenous [human]) is the antitoxin of choice for specific treatment of infant botulism in the United States.  However, its high cost limits its use in many countries.  These investigators reported the effectiveness and safety of equine botulinum antitoxin (EqBA) as an alternative treatment.  They conducted an analytical, observational, retrospective, and longitudinal study on cases of infant botulism registered in Mendoza, Argentina, from 1993 to 2007.  They analyzed 92 medical records of laboratory-confirmed cases and evaluated the safety and efficacy of treatment with EqBA.  Forty-nine laboratory-confirmed cases of infant botulism demanding admission in ICUs and mechanical ventilation included 31 treated with EqBA within the 5 days after the onset of signs and 18 untreated with EqBA.  EqBA-treated patients had a reduction in the mean length of hospital stay of 23.9 days (p = 0.0007).  For infants treated with EqBA, the ICU stay was shortened by 11.2 days (p = 0.0036), mechanical ventilation was reduced by 11.1 days (p = 0.0155), and tube feeding was reduced by 24.4 days (p = 0.0001).  The incidence of sepsis in EqBA-treated patients was 47.3 % lower (p = 0.0017) than in the untreated ones.  Neither sequelae nor adverse effects attributable to EqBA were noticed, except for 1 infant who developed a transient erythematous rash.  The authors concluded that these results suggested that prompt treatment of infant botulism with EqBA is safe and effective and that EqBA could be considered an alternative specific treatment for infant botulism when BabyBIG is not available.

Also, an UpToDate review on “Botulism” (Pegram and Stone, 2012) states that “Human-derived botulinum immune globulin -- Human-derived botulinum immune globulin (called BIG-IV or BabyBIG) is available for intravenous use in infants less than one year of age who are diagnosed with infant botulism.  BIG-IV should be administered as early as possible in the illness”.

BabyBIG, botulism immune globulin intravenous (human) (BIG-IV), is an orphan drug that consists of human-derived botulism antitoxin antibodies that is approved by the FDA for the treatment of infant botulism types A and B.

BabyBIG is given as a single IV infusion.  Recommended dose is 1.5 mL/kg (75 mg/kg) given as a single intravenous infusion.  Begin infusion slowly (0.5 mL/kg/h); if no untoward reaction in 15 minutes, increase rate to 1.0 mL/kg/h (2.2, 2.3).  (At the recommended rates, infusion of the indicated dose should take 97.5 minutes total elapsed time).   

Table: CPT Codes / ICD-10 Codes / HCPCS Codes
Code Code Description

Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":

Hepatitis A Immune Globulin:

CPT codes covered if selection criteria are met [no specific code]:

90399 Unlisted immune globulin
96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

HCPCS codes covered if selection criteria are met:

J1460 Injection, gamma globulin, intramuscular, 1 cc [GamaSTAN S/D (formerly BayGam) not covered for individuals with clinical manifestations of hepatitis A or in those exposed more than 2 weeks previously]
J1560 Injection, gamma globulin, intramuscular, over 10 cc [GamaSTAN S/D (formerly BayGam) not covered for individuals with clinical manifestations of hepatitis A or in those exposed more than 2 weeks previously]

ICD-10 codes covered if selection criteria are met:

Z20.5 Contact with and (suspected) exposure to viral hepatitis
Z20.6 Contact with and (suspected) exposure to human immunodeficiency virus [HIV]
Z20.828 Contact with and (suspected) exposure to other viral communicable diseases

ICD-10 codes not covered for indications listed in the CPB:

B15.0 Hepatitis A with hepatic coma
B15.9 Hepatitis A without hepatic coma

Hepatitis B Immune Globulin:

CPT codes covered if selection criteria are met:

90371 Hepatitis B immune globulin (HBIg), human, for intramuscular use

HCPCS codes covered if selection criteria are met:

J1571 Injection, hepatitis B immune globulin (Hepagam B), intramuscular, 0.5 ml
J1573 Injection, hepatitis B immune globulin (Hepagam B), intravenous, 0.5 ml

ICD-10 codes covered if selection criteria are met:

Z20.5 Contact with and (suspected) exposure to viral hepatitis [Hepatitis B] [Not covered for prevention of mother -to-child transmission of hepatitis B virus during pregnancy]
Z48.23 Encounter for aftercare following liver transplant
Z57.8 Occupational exposure to other risk factors [exposure to potenially hazardous bodily fluids]
Z94.4 Liver transplant status

ICD-10 codes not covered for indications listed in the CPB:

B16.0 - B16.9
B18.0 - B18.1
B19.10 - B19.11
Hepatitis B
Z86.19 Personal history of other infectious and parasitic diseases [Not covered for prevention of mother -to-child transmission of hepatitis B virus during pregnancy]

Cytomegalovirus Immune Globulin:

CPT codes covered if selection criteria are met:

90291 Cytomegalovirus immune globulin (CMV-IgIV), human, for intravenous use

HCPCS codes covered if selection criteria are met:

J0850 Injection, cytomegalovirus immune globulin intravenous (human), per vial

ICD-10 codes covered if selection criteria are met:

B25.0 - B25.9 Cytomegaloviral disease
O35.3xx+ Maternal care for (suspected) damage to fetus from viral disease in mother [cytomegalovirus]
P35.1 Congenital cytomegalovirus infection
T86.00 - T86.99 Complications of transplanted organs and tissues
Z20.828 Contact with and (suspected) exposure to other viral communicable diseases [cytomegalovirus]
Z48.21 - Z48.298 Encounter for aftercare following organ transplant
Z94.0 - Z94.9 Transplanted organ and tissue status

ICD-10 codes not covered for indications listed in the CPB:

C88.0 Waldenstrom macroglobulinemia
D80.2 Selective deficiency of immunoglobulin A [IgA]
O98.811 - O98.83 Other maternal infectious and parasitic diseases complicating pregnancy, childbirth or puerperium [cytomegalovirus infection] [in utero]

Rho-D immune Globulin:

CPT codes covered if selection criteria are met:

90384 Rho(D) immune globulin (RHIg), human, full-dose, for intramuscular use
90385 Rho(D) immune globulin (RHIg), human, mini-dose, for intramuscular use
90386 Rho(D) immune globulin (RHIgIV), human, for intravenous use

Other CPT codes related to the CPB:

59000 Amniocentesis
59012 Cordocentesis (intrauterine), any method
59015 Chorionic villus sampling, any method
59072 Fetal umbilical cord occlusion, including ultrasound guidance
59074 Fetal fluid drainage (eg, vesicocentesis, thoracocentesis, paracentesis), including ultrasound guidance
59076 Fetal shunt placement, including ultrasonic guidance
59412 External cephalic version, with or without tocolysis
59812 - 59857 Abortion

HCPCS codes covered if selection criteria are met:

J2788 Injection, Rho D immune globulin, human, minidose, 50 mcg
J2790 Injection, Rho D immune globulin, human, full dose, 300 mcg
J2791 Injection, Rho D immune globulin, human (Rhophylac), intramuscular or intravenous, 10 IU
J2792 Injection, Rho D immune globulin, intravenous, human, solvent detergent, 100 IU

ICD-10 codes covered if selection criteria are met:

D69.3 Immune thrombocytopenia purpura
O00.00 - O00.91 Ectopic pregnancy
O02.1 Missed abortion
O03.0 - O03.9 Spontaneous abortion
O36.4xx0 - O36.4xx9 Maternal care for intrauterine death
O44.10 - O44.13 Hemorrhage from placenta previa
O45.001 - O45.93 Premature separation of placenta [abruptio placentae]

Rabies Immune Globulin:

CPT codes covered if selection criteria are met:

90375 Rabies immune globulin (RIg), human, for intramuscular and/or subcutaneous use
90376 Rabies immune globulin, heat-treated (RIg-HT), human, for intramuscular and/or subcutaneous use

ICD-10 codes covered if selection criteria are met:

Z20.3 Contact with and (suspected) exposure to rabies

Varicella Zoster Immune Globulin:

CPT codes covered if selection criteria are met:

90396 Varicella-zoster immune globulin, human, for intramuscular use
96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

HCPCS codes covered if selection criteria are met:

J1460 Injection, gamma globulin, intramuscular, 1 cc [GamaSTAN S/D (formerly BayGam) covered for prevention in immunosuppressed persons, if varicella zoster immune globulin is unavailable]
J1470 Injection, gamma globulin, intramuscular, 2 cc
J1480 Injection, gamma globulin, intramuscular, 3 cc
J1490 Injection, gamma globulin, intramuscular, 4 cc
J1500 Injection, gamma globulin, intramuscular, 5 cc
J1510 Injection, gamma globulin, intramuscular, 6 cc
J1520 Injection, gamma globulin, intramuscular, 7 cc
J1530 Injection, gamma globulin, intramuscular, 8 cc
J1540 Injection, gamma globulin, intramuscular, 9 cc
J1550 Injection, gamma globulin, intramuscular, 10 cc
J1560 Injection, gamma globulin, intramuscular, over 10 cc [GamaSTAN S/D (formerly BayGam) covered for prevention in immunosuppressed persons, if varicella zoster immune globulin is unavailable]

ICD-10 codes covered if selection criteria are met:

B20 Human immunodeficiency virus [HIV] disease
Z20.820 Contact with and (suspected) exposure to varicella

Tetanus Immune Globulin:

CPT codes covered if selection criteria are met:

90389 Tetanus immune globulin (TIg), human, for intramuscular use

HCPCS codes covered if selection criteria are met:

J1670 Injection tetanus immune globulin, human, up to 250 units

ICD-10 codes covered if selection criteria are met:

M72.6 Necrotizing fasciitis
T20.00x+ - T25.799+ Burns and corrosions of external body surface, specified by site [contaminated, necrotizing]
Numerous options Open wound [complicated only] [contaminated, necrotizing, puncture] [Codes not listed due to expanded specificity]
Numerous options Superficial injury [infected only] [contaminated, necrotizing, puncture] [Codes not listed due to expanded specificity]

Rubeola (Measles) Immune Globulin:

CPT codes covered if selection criteria are met [no specific code]:

90399 Unlisted immune globulin
96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

HCPCS codes covered if selection criteria are met:

J1460 Injection, gamma globulin, intramuscular, 1 cc [GamaSTAN S/D (formerly BayGam) covered for one who has not been vaccinated, has not had measles, and was exposed less than 6 days previously]
J1470 Injection, gamma globulin, intramuscular, 2 cc
J1480 Injection, gamma globulin, intramuscular, 3 cc
J1490 Injection, gamma globulin, intramuscular, 4 cc
J1500 Injection, gamma globulin, intramuscular, 5 cc
J1510 Injection, gamma globulin, intramuscular, 6 cc
J1520 Injection, gamma globulin, intramuscular, 7 cc
J1530 Injection, gamma globulin, intramuscular, 8 cc
J1540 Injection, gamma globulin, intramuscular, 9 cc
J1550 Injection, gamma globulin, intramuscular, 10 cc
J1560 Injection, gamma globulin, intramuscular, over 10 cc [GamaSTAN S/D (formerly BayGam) covered for one who has not been vaccinated, has not had measles, and was exposed less than 6 days previously]

ICD-10 codes covered if selection criteria are met:

Z20.828 Contact with and (suspected) exposure to other viral communicable diseases [rubeola (measles)]

Immune Globulin (IVIG) for German Measles (Rubella):

CPT codes covered if selection criteria are met [no specific code]:

90399 Unlisted immune globulin

HCPCS codes covered if selection crieria are met:

J1460 Injection, gamma globulin, intramuscular, 1 cc
J1470 Injection, gamma globulin, intramuscular, 2 cc
J1480 Injection, gamma globulin, intramuscular, 3 cc
J1490 Injection, gamma globulin, intramuscular, 4 cc
J1500 Injection, gamma globulin, intramuscular, 5 cc
J1510 Injection, gamma globulin, intramuscular, 6 cc
J1520 Injection, gamma globulin, intramuscular, 7 cc
J1530 Injection, gamma globulin, intramuscular, 8 cc
J1540 Injection, gamma globulin, intramuscular, 9 cc
J1550 Injection, gamma globulin, intramuscular, 10 cc
J1560 Injection, gamma globulin, intramuscular, over 10 cc

ICD-10 codes covered if selection criteria are met:

Z20.4 Contact with and (suspected) exposure to rubella

Immune Globulin (IGIM) for German Measles (Rubella):

HCPCS codes not covered for conditions listed in the CPB:

J1460 Injection, gamma globulin, intramuscular, 1 cc [GamaSTAN S/D (formerly BayGam) not covered for Rubella prophylaxis]
J1560 Injection, gamma globulin, intramuscular, over 10 cc [GamaSTAN S/D (formerly BayGam) not covered for Rubella prophylaxis]

ICD-10 codes not covered for conditions listed in the CPB:

O98.511 - O98.53 Other viral diseases complicating pregnancy, childbirth and puerperium [rubella]

Vaccinia (Smallpox) Immune Globulin:

CPT codes covered if selection criteria are met:

90393 Vaccinia immune globulin, human, for intramuscular use

ICD-10 codes covered if selection criteria are met:

T88.1xx+ Other complications following immunization, not elsewhere classified
Z20.828 Contact with and (suspected) exposure to other viral ncommunicable diseases [vaccinia (smallpox)]

ICD-10 codes contraindicated for this CPB:

H16.001 - H16.9 Keratitis

Infantile Botulism Immune Globulin:

CPT codes covered if selection criteria are met:

90288 Botulism immune globulin, human, for intravenous use [BabyBIG or BIG-IV]

Other CPT codes related to the CPB:

96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour
96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure)

ICD-10 codes covered if selection criteria are met:

A48.51 Infant botulism

Immune Globulin Deficiency (IgG):

CPT codes covered if selection criteria are met:

96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

HCPC codes covered if selection criteria are met:

J1460 Injection, gamma globulin, intramuscular, 1 cc [GamaSTAN S/D (formerly BayGam) covered for Immunoglobulin deficiency, to prevent serious infection if circulating IgG levels of approximately 200 mg/dL plasma are maintained]
J1560 Injection, gamma globulin, intramuscular, over 10 cc [GamaSTAN S/D (formerly BayGam) not covered for Rubella prophylaxis]

The above policy is based on the following references:

  1. American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists (ACOG). Guidelines for Perinatal Care. 4th ed. Elk Grove Village, IL: AAP; August 1997.
  2. American Academy of Pediatrics (AAP). 1997 Red Book. Report of the Committee on Infectious Diseases. 24th ed. Elk Grove Village, IL: AAP; 1997.
  3. Centers for Disease Control and Prevention. Rubella prevention. Recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR Recomm Rep.1990;39(RR-15):1-18.
  4. Centers for Disease Control and Prevention. Hepatitis B: A comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination. Recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR Recomm Rep. 1991;40(RR-13):1-25.
  5. Centers for Disease Control and Prevention. Prevention of varicella. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 1996;45(RR-11):1-36.
  6. Centers for Diseae Control. Recommendations of the Immunization Practices Advisory Committee. Varicella-zoster immune globulin for the prevention of chickenpox. Ann Intern Med. 1984;100(6):859-865.
  7. Centers for Disease Control and Prevention. Measles, mumps, and rubella -- vaccine use and strategies for the elimination of measles, rubella, and congenital rubella syndrome and control of mumps: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 1998;47(RR-8):1-57.
  8. Centers for Disease Control. Rabies prevention -- United States, 1984. MMWR Morb Mortal Wkly Rep. 1984;33(28):393-402, 407-408.
  9. Centers for Disease Control and Prevention. Prevention of hepatitis A through active or passive immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 1996;45(RR-15):1-30.
  10. Centers for Disease Control and Prevention. Diptheria, tetanus, and pertussis: Recommendations for vaccine use and other preventive measures. Recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR Recomm Rep. 1991;40(RR-10):1-28.
  11. Falagas ME. Cytomegalovirus immune globulin (CMVIG) prophylaxis is associated with increased survival after orthotopic liver transplantation. The Boston Center for Liver Transplantation CMVIG Study Group. Clin Transplant. 1997;11(5 Pt 1):432-437.
  12. Gajarski RJ. Outcomes among pediatric heart transplant recipients. Tex Heart Inst J. 1997;24(2):97-104.
  13. Dickinson BI, Gora-Harper ML, McCraney SA, Gosland M. Studies evaluating high-dose acyclovir, intravenous immune globulin, and cytomegalovirus hyperimmunoglobulin for prophylaxis against cytomegalovirus in kidney transplant recipients. Ann Pharmacother. 1996;30(12):1452-1464.
  14. Centers for Disease Control and Prevention. Vaccinia (smallpox) vaccine. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 1991;40(RR-14):1-10.
  15. Crowther CA, Middleton P. Anti-D administration after childbirth for preventing Rhesus alloimmunisation. Cochrane Database Syst Rev. 1997;(2):CD000021.
  16. Crowther CA, Middleton P. Anti-D administration in pregnancy for preventing Rhesus alloimmunisation. Cochrane Database Syst Rev. 1999;(2):CD000020.
  17. Health Technology Board for Scotland (HTBS). The use of anti-D prophylaxis for rhesus negative women in pregnancy. Understanding HTBS Advice. Glasgow, Scotland; HTBS; 2002.
  18. Centers for Disease Control and Prevention (CDC). Use of smallpox (vaccinia) vaccine, June 2002. Supplemental recommendation of the ACIP. Atlanta, GA: CDC; June 2002.  
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