§1028.6. Required coverage for pediatric acute-onset neuropsychiatric syndrome (PANS);
pediatric autoimmune neuropsychiatric disorders associated with streptococcal
infections (PANDAS); types of autoimmune encephalitis (AE)
A. Every health coverage plan renewed, delivered, or issued for delivery in this state
shall provide coverage for PANS, PANDAS, and other types of AE, including but not limited
to the use of intravenous immunoglobulin therapy. The coverage provided in this Section
may be subject to annual deductibles, coinsurance, and copayment provisions as are
consistent and established under the health coverage plan.
B.
(1)In making determinations of coverage for PANDAS, PANS, and other types
of AE, insurers may consider but not require strict adherence to other treatment options or
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§1028.6. Required coverage for pediatric acute-onset neuropsychiatric syndrome (PANS);
pediatric autoimmune neuropsychiatric disorders associated with streptococcal
infections (PANDAS); types of autoimmune encephalitis (AE)
A. Every health coverage plan renewed, delivered, or issued for delivery in this state
shall provide coverage for PANS, PANDAS, and other types of AE, including but not limited
to the use of intravenous immunoglobulin therapy. The coverage provided in this Section
may be subject to annual deductibles, coinsurance, and copayment provisions as are
consistent and established under the health coverage plan.
B.(1) In making determinations of coverage for PANDAS, PANS, and other types
of AE, insurers may consider but not require strict adherence to other treatment options or
recommendations developed by a medical professional consortium convened for the purposes
of researching, identifying, and publishing best practice standards for diagnosis and treatment
of these disorders, such as the PANDAS Physician Network. The treatment should be based
on evidence of positive patient outcomes.
(2) A health coverage plan may limit intravenous immunoglobulin treatments to no
more than three monthly courses of treatment, unless additional treatment is deemed
medically necessary based on a clinical review using such guidelines.
C. For the purposes of this Section, the following terms apply:
(1) "Autoimmune encephalitis" or "AE" means any type of post infectious
encephalitis where the immune system attacks the brain.
(2) "Health coverage plan" means any hospital, health, or medical expense insurance
policy, hospital or medical service contract, employee welfare benefit plan, contract, or other
agreement with a health maintenance organization or a preferred provider organization,
health and accident insurance policy, or any other insurance contract of this type in this state,
including a group insurance plan and a self-insurance plan. "Health coverage plan" does not
include the Office of Group Benefits programs, a plan providing coverage for excepted
benefits as defined in R.S. 22:1061, limited benefits health insurance plans, or short-term
policies that have a term of less than twelve months.
(3) "Pediatric acute-onset neuropsychiatric disorders associated with streptococcal
infections" or "PANDAS" means a condition where there is evidence of an abnormal
autoimmune or inflammatory response in the brain following streptococcal infections.
(4) "Pediatric acute-onset neuropsychiatric syndrome" or "PANS" means a condition
defined by the sudden onset of obsessive-compulsive symptoms or severe eating restrictions,
along with at least two other cognitive, behavioral, or neurological symptoms.
D. This Section shall be known and may be cited as the "The Gillian Guiffreda Act".