24.3.20.8 Respiratory Syncytial Virus (RSV) ProphylaxisThe CSHCN Services Program considers the American Academy of Pediatrics (AAP) criteria as the most useful single reference describing the evidence basis for RSV prophylaxis medical necessity. Palivizumab RSV immune globulin for IM use (RSV-IgIM) (Synagis) and RSV immune globulin for intravenous use (RSV-IgIV) (Respigam) are covered benefits for clients when medically necessary and prior authorized. Based upon RSV surveillance data and the expert opinion of CSHCN Services Program specialists and others, the RSV season in the state of Texas is expected to begin on October 1 of each calendar year. The season of widespread RSV activity in Texas typically ends in late March. These dates may change based upon expert opinion, and providers are notified by banner messages or bulletin articles when changes occur. All palivizumab requires prior authorization through the CSHCN Services Program. All requests for palivizumab must be submitted with the CSHCN Services Program "CSHCNProgram Prior Authorization Request for Palivizumab (Synagis)" found in Appendix B on page B-18. The physician's original, handwritten signature is required on the form and must be maintained in the client record. Hospitalized infants determined to be at risk of severe RSV disease should receive their first dose of RSV prophylaxis 48 to 72 hours before being discharged during the RSV season. Discharge planning should arrange outpatient follow-up for continued administration of palivizumab if medically indicated. Prophylaxis may begin in the two weeks preceding the start of the RSV season. Providers may start submitting for prior authorization beginning September 1, with an administration date starting on or after October 1. Subsequent doses of palivizumab should be given approximately every 30 days. Clients will continue with 4 more doses, with the last dose given by February 28 for those starting in October. Clients starting on or after November 1 should continue approximately every 30 days 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 will continue with 5 more doses, with the last dose given by February 28. Note: The age requirements detailed below refer to the age of the client at the beginning of the RSV season, which is defined as October 1 of each calendar year. Palivizumab is not reimbursed for CSHCN Services Program clients who are 24 months of age or older at the start of the RSV season in Texas. Palivizumab may be prior authorized for clients less than 24 months of age who have underlying lung disease when the documentation submitted demonstrates the following:
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• The following is a list of the most common diagnosis codes for significant lung disease:
Note: Chronic lung disease (CLD), also known as chronic respiratory disease arising in the perinatal period (diagnosis code 7707), 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 (RSD). 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 CSHCN Services Program beneficiaries who are less than 24 months of age who have hemodynamically significant heart disease when the documentation submitted demonstrates one of the following:
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• The following is a list of the most common cardiac diagnosis codes;
Palivizumab may be prior authorized for CSHCN Services Program beneficiaries less than 12 months of age when documentation includes a diagnosis code indicating the client was born at 28 weeks estimated gestational age or earlier: (diagnosis codes 76521, 76522, 76523, or 76524). Palivizumab may be prior authorized for CSHCN Services Program beneficiaries less than six months of age when the documentation includes one of the following:
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• The following is a list of diagnosis codes for congenital airway anomalies:
Providers may request prior authorization for RSV prophylaxis through the CSHCN Services Program for clients with medical conditions not otherwise delineated above. All such requests must include documentation to support the determination of medical necessity for this service. Providers seeking additional information on RSV may contact DSHS or refer to the DSHS website at www.dshs.state.tx.us. Reimbursement Palivizumab will not be reimbursed for dates of service outside the RSV season. Exception: Palivizumab may be reimbursed for two weeks preceding the start of the RSV season. Palivizumab will not be reimbursed for CSHCN Services Program beneficiaries who are greater than or equal to 24 months of age at the start of the RSV season in Texas. The CSHCN Services Program may consider reimbursement for the IM 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 CSHCN Services Program only reimburses providers for waste 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 child and 20 mg is wasted, 200 services/units must be billed, not four services/units. RSV prophylaxis medications are a benefit in the home, office, or outpatient settings. Providers may not bill TMHP-CSHCN Services Program if the RSV prophylaxis was obtained through the Vendor Drug Program. RSV prophylaxis is reimbursed at the lower of the billed amount or the amount allowed by the Texas Medicaid Program. |
Active treatment for lung disease within the 6 months that precede the start of the RSV season (i.e., treatment dates between April 1 and September 30) consisting of one of the following:
