CodeMap® LCD-L34771

Contractor Information

Contractor Name: Wisconsin Physicians Service Insurance Corporation - Full list of policies of this Medicare Contractor

Contractor Number: 05302
Contractor Type: MAC B

LCD Information

LCD ID Number: L34771 Status: A-Approved
LCD Title: Immune Globulins
Geographic Jurisdiction: Missouri - Entire State, Missouri - Northwestern Other Jurisdictions
Original Determination Effective Date: 10/01/2015
Original Determination Ending Date:
Revision Effective Date: 02/29/2024
Revision End Date:
CMS National Coverage Policy:
CMS Pub 100-02 Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services, Section 50.6 – Coverage of Intravenous Immune Globulin for Treatment of Primary Immune Deficiency Diseases in the Home.

CMS Pub 100-03 Medicare National Coverage Determination (NCD) Manual, Chapter 1, Part 4, Section 250.3 – Intravenous Immune Globulin for the Treatment of Autoimmune Mucocutaneous Blistering Diseases.

CMS Pub 100-04 Medicare Claims Processing Manual, Chapter 17 – Drugs and Biologicals, Section 80.6 – Intravenous Immune Globulin (Change Requests 2149, 3745, 4244, 5635, 5643, and 5981).

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06/25/2025 02:26:09 18.97.14.90

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