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43.4.2 Respiratory Syncytial Virus (RSV) Prophylaxis
The Texas Medicaid Program considers the AAP criteria as the most useful single reference describing the evidence basis for RSV prophylaxis medical necessity. RSV immune globulin, intramuscular palivizumab (Synagis) is a benefit of THSteps-CCP when medically necessary.
Based upon RSV surveillance data and the expert opinion of Texas-based specialists, the RSV season in Texas is expected to start on October 1 of each calendar year. This date may change each calendar year, based upon feedback from experts. Prophylaxis may begin in the two weeks preceding the start of the season.
Beginning at 6 months of age, all high-risk infants, including those who qualify for RSV prophylaxis, and their contacts should be immunized against influenza, unless influenza immunization is medically contraindicated in the case of a specific individual.
During the RSV season, hospitalized infants determined to be at risk of severe RSV disease should receive their first dose of RSV prophylaxis 48-72 hours before being discharged.
Discharge planning should arrange outpatient follow-up for continued administration of palivizumab if medically indicated. Subsequent doses of palivizumab should be given approximately every 30 days.
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