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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 : 8.2.54.2 Prior Authorization Requirements

8.2.54.2
All RSV prophylaxis injections require prior authorization through CCP. All requests for RSV prophylaxis must be submitted to 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 are required on the form and must be maintained in the client’s medical record.
Providers may submit prior authorization requests beginning September 1 for an administration date starting on or after October 1, and beginning October 1 for an administration date starting on or after November 1. Subsequent doses of RSV prophylaxis should be given approximately every 30 days. Clients continue with 4 more doses, with the last dose given by February 28 for those starting in October. Clients starting in November should continue approximately every 30 days until a stop date of March 31.
RSV prophylaxis may be prior authorized for Medicaid clients who are birth through 23 months of age who have congenital heart disease. For Medicaid clients who are birth through 23 months of age who have congenital heart disease, documentation submitted must demonstrate at least one of the following:
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)
RSV prophylaxis may be prior authorized for Medicaid clients who are 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:
Palivizumab may be prior authorized for clients who are birth through 11 months of age when documentation includes one of the following:
Palivizumab may be prior authorized for clients who are birth through 5 months of age when documentation includes one of the following:
A diagnosis code that indicates the infant was born at 32 weeks through 34 weeks, 6 days gestational age and documentation of two of the following in the client’s medical record:
Palivizumab may be prior authorized for Medicaid clients who are birth through 1 year of age who have had a stem cell or solid organ transplant.
Providers may request prior authorization for RSV prophylaxis through 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.

Texas Medicaid & Healthcare Partnership
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