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43.4.2.2 Prior Authorization
All palivizumab requires prior authorization through THSteps-CCP.
All requests for palivizumab must be submitted to THSteps-CCP on a completed Texas Medicaid Palivizumab (Synagis) Prior Authorization Request Form.
The form must be signed and dated by the ordering physician. The physician's original, handwritten signature and date is required on the form and must be maintained in client's medical record.
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. This date may change each calendar year, based upon feedback from experts.
Providers may start submitting for prior authorization beginning September 1, with an administration date starting on or after October 1.
Clients starting on or after November 1 should continue approximately every 30 days until a stop date of March 31.
Subsequent doses of palivizumab should be given approximately every 30 days. Clients continue with four more doses, with the last dose given by February 28 for those starting in October. Clients starting late in the season should continue until a stop date of March 31.
Hospitalized infants determined to be at risk of severe RSV disease in September may receive the first injection before October 1 before discharge from the hospital. Clients continue with five more doses, with the last dose given by February 28.
Palivizumab may be prior authorized for Medicaid clients birth through 23 months of age who have hemodynamically significant heart disease when the documentation submitted demonstrates at least one of the following:
• The presence of moderate to severe pulmonary hypertension.
•Active treatment for and diagnosis of hemodynamically significant heart disease, including both of the following documentation requirements:
•Active treatment for hemodynamically significant heart disease within the six months preceding the start of the RSV season (i.e., treatment dates between April 1 and September 30) consisting of digitalis, diuretics, or supplemental oxygen.
•A diagnosis code consistent with hemodynamically significant congenital heart disease (i.e., congenital anatomical cardiac defects or cardiomyopathies of any etiology).
The following table lists the most common cardiac diagnosis codes:
Palivizumab may be prior authorized for Medicaid clients birth through 23 months of age who have underlying lung disease when the documentation submitted demonstrates the following:
•Active treatment for lung disease within the six months preceding the start of the RSV season (i.e., treatment dates between April 1 and September 30) consisting of one of the following:
•Corticosteroids (systemic or inhaled), diuretics, or supplemental oxygen therapy.
•Mechanical ventilation.
•One of the following diagnoses of significant lung disease:
•Chronic respiratory failure.
•Chronic respiratory disease arising in the perinatal period.
•Cystic fibrosis.
•Congenital bronchiectasis.
•Diaphragmatic defects.
•Congenital cystic lung disease.
•Congenital agenesis, hypoplasia and dysplasia of lung.
•Other respiratory diagnoses with supportive documentation of medical necessity.
The following table identifies common chronic lung disease (CLD) diagnosis codes:
Note: CLD, also known as chronic respiratory disease arising in the perinatal period, was formerly called bronchopulmonary dysplasia. It can develop in pre-term neonates treated with oxygen and positive pressure ventilation. Many cases are seen in infants who previously had respiratory distress syndrome (RDS). CLD is characterized by disordered lung growth and a reduction in the number of structures available for gas exchange. CLD is not asthma, croup, recurrent upper respiratory infections, chronic bronchitis, chronic bronchiolitis, or a history of a previous RSV infection.
Palivizumab may be prior authorized for Medicaid clients birth through 11 months of age when documentation includes a diagnosis code indicating the client was born at 28 weeks estimated gestational age or earlier (76521, 76522, 76523, or 76524).
Palivizumab may be prior authorized for Medicaid clients birth through 5 months of age when the documentation includes:
•A diagnosis code indicating the infant was born at 29-32 weeks estimated gestational age (76525 or 76526).
•A diagnosis code indicating the infant was born between 32 and 35 weeks gestational age (76526, 76527, or 76528) and documentation of severe neuromuscular disease (including chronic respiratory failure [51883]).
•Significant congenital anomalies of the airway, including diagnosis code 7480, 7482, and 7503, which is expected to compromise respiratory reserve, or documentation of two of the following:
•Direct exposure to tobacco smoke or documented environmental air pollutants.
•Regular childcare attendance.
•Direct exposure to siblings who attend childcare or school outside of the home.
Palivizumab may be prior authorized for Medicaid clients than have stem cell transplants or solid organ transplant and are birth through 23 months of age. The following table lists diagnosis codes related to transplants:
Providers may request prior authorization for RSV prophylaxis through THSteps-CCP for clients with medical conditions not otherwise noted. All such requests must provide documentation to support the determination of medical necessity for this service.
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