02/05/2026
Good news! Aetna Updates Medical Policy to Include IVIG Coverage for PANS/PANDAS Treatment.
The new policy allows coverage for intravenous immunoglobulin (IVIG) for Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) / Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS), when patients who meet certain diagnostic and clinical criteria:
"Therapy is considered medically necessary for treatment when the following criteria are met:
Child meets PANS Research Consortium Diagnostic Criteria for PANS/PANDAS:
Documentation of abrupt, dramatic onset (within less than one month) of obsessive-compulsive disorder or severely restricted food intake; and
Documentation of concurrent presence of additional neuropsychiatric symptoms, with similarly severe and acute onset, from at least two of the following seven categories:
Anxiety;
Emotional lability and/or depression;
Irritability, aggression, and/or severely oppositional behaviors;
Behavioral (developmental) regression;
Deterioration in school performance (related to attention deficit/hyperactivity disorder (ADHD)-like symptoms, memory deficits, cognitive changes);
Sensory or motor abnormalities;
Somatic signs and symptoms, including sleep disturbances, enuresis, or urinary frequency; and
Onset of symptoms occurs between 3 years of age and puberty; and
Documentation that other causes of symptoms have been ruled out; and
Child has tried and failed treatment with systemic corticosteroids; and
Documented objective assessment of baseline symptoms has been submitted (e.g., Children's Yale-Brown Obsessive-Compulsive Scale [CY-BOCS], Clinical Global Impression of Severity [CGIS], Parent-Rated Pediatric Acute Neuropsychiatric Symptom Scale [PANS Scale]);
Continued therapy is considered medically necessary when documentation of objective clinical response to therapy has been submitted (e.g., Children's Yale-Brown Obsessive-Compulsive Scale [CY-BOCS], Clinical Global Impression of Severity [CGIS], Parent-Rated Pediatric Acute Neuropsychiatric Symptom Scale [PANS Scale])."
According to Aetna commercial benefit plans, health care services are considered not medically necessary if they are more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that mem...
