Criteria
Coverage is subject to the specific terms of the member's benefit plan.
The use of palivizumab (Synagis) may be considered medically necessary when the following is met:
- The individual must have one of the following diagnoses and the additional criteria outlined for diagnosis:
- Prematurity:
- < 29 weeks, 0 days gestational age; and
- ≤12 months of age at start of RSV season
- Chronic Lung Disease of Prematurity (CLD)
- ≤12 months of age at start of RSV season
- < 32 weeks, 0 days gestational age; and
- Requires supplemental oxygen > 21% for at least the first 28 days after birth
- 13-24 months of age at start of RSV season
- < 32 weeks, 0 days gestational age; and
- Requires supplemental oxygen > 21% for at least the first 28 days after birth; and
- Continues to receive medical support within six months before the start of RSV season with supplemental oxygen, diuretic, or chronic corticosteroid therapy
- Congenital Heart Disease
- ≤12 months of age at start of RSV season; and
- Hemodynamically significant cyanotic or acyanotic congenital heart disease with medical therapy required.
Authorization: 5 months (allows for 5 monthly doses between October 19th through April 21st)
Palivizumab (Synagis) for any other indication is considered experimental/investigational and therefore, non-covered. Available scientific evidence does not support its use for any other indication.
Procedure Codes
