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43.4.2.3 Benefits and Limitations
Palivizumab is not reimbursed for dates of service outside the RSV season.
Exception: Palivizumab may be reimbursed for two weeks preceding the start of the RSV season for hospitalized infants determined to be at risk of severe RSV disease in September.
Palivizumab injections given during an inpatient hospital stay are considered included in the hospital DRG and are not separately reimbursed.
Palivizumab is not reimbursed for Medicaid clients 24 months of age or older at the start of the RSV season in Texas.
THSteps-CCP may consider reimbursement for the intramuscular version of the RSV prophylaxis when billed with procedure code 1-90378. Palivizumab is provided in single use vials and must be billed per mg. Providers are required to maintain accurate records of the total number of units given and the total number of units purchased, administered and wasted for each client. If billing waste, the total number of units billed must include the number of units wasted. The Texas Medicaid Program reimburses providers for waste only if a partial vial is actually wasted and not if the partial vial is used for another patient.
Example: If 180 mg is administered to a client and 20 mg is wasted, 200 services/units must be billed, not four services/units.
Reimbursement is provided no more than once approximately every 30 days. RSV prophylaxis medications are covered in the home, office, or outpatient settings.
Providers may not bill the Texas Medicaid Program if the RSV prophylaxis was obtained through the VDP.
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