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2012 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 8. Physician : 8.2 Services, Benefits, Limitations, and Prior Authorization : 8.2.54 Palivizumab Injections

8.2.54
Texas Medicaid 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 CCP when medically necessary.
Based upon RSV surveillance data and the expert opinion of Texas-based specialists, the beginning of RSV season in Texas starts on different dates based on the region. The RSV season is expected to start no earlier than October 1 for all regions, except regions 1, 9, and 10. For regions 1, 9, and 10, the RSV season is expected to start no earlier than November 1 of each calendar year.
During the RSV season, hospitalized infants determined to be at risk of severe RSV disease in September should receive their first dose of RSV prophylaxis 48–72 hours before being discharged. Clients will continue with five more doses. Discharge planning should arrange outpatient follow-up for continued administration of RSV prophylaxis if medically indicated.
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.

Texas Medicaid & Healthcare Partnership
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