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Synagis (palivizumab) Precertification Request Form — Pediatrics/Neonatology
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This document is Aetna's precertification request form and instructions for providers requesting approval for Synagis (palivizumab) injections to prevent serious RSV lower respiratory tract disease; it governs submission requirements and clinical information collection for pediatric/neonatal patients. It affects prescribers, dispensing providers, and infusion centers submitting prior authorization for Synagis.
No material clinical or coverage changes in this revision.
Coverage Criteria & Eligibility
Eligibility data elements collected
Coverage evaluation is based on documented high-risk status and RSV season timing; the form collects the following required clinical data elements:
From form fields.
Form provides checkbox for prematurity and requests gestational age.
Form fields capture CLD details.
Form fields capture CHD details.
Form fields capture airway/neuromuscular details.
Form fields capture CF details.
Form fields capture immunocompromised details.
The precertification form asks whether the request is an off-season request and whether regional RSV activity meets NREVSS thresholds. Specifically, it asks: is RSV activity ≥10% by rapid antigen testing or ≥3% by PCR for the requested region or state within 2 weeks of the intended dose? This information is collected to determine whether an off-season dose may be appropriate and will be used in the coverage evaluation.
Providers must include this NREVSS activity check on the form when submitting a request for Synagis (palivizumab), regardless of whether the request is for initiation or continuation of monthly dosing.
If the request is marked as an off-season request and the regional RSV activity does not meet the NREVSS thresholds (i.e., RSV activity is below 10% by rapid antigen or below 3% by PCR within 2 weeks of the intended dose), the form indicates that this information will be used to evaluate the request. Off-season requests may be less likely to be approved when the NREVSS activity criteria are not met.
Providers should include all required clinical documentation (gestational age at birth, prior doses this RSV season, and relevant comorbid conditions) to support any off-season request, as the absence of regional activity per NREVSS is a factor in the review.
Coding and Activity Thresholds
| Administration code(s) (CPT) | Administration CPT codes to be provided on form |
| Primary ICD code | Primary diagnosis ICD code (to be provided) |
| Secondary ICD code | Secondary diagnosis ICD code (to be provided) |
| Other ICD code | Other applicable ICD codes (to be provided) |
Provider Instructions, Documentation & Requirements
Prior Authorization Required
Prior authorization (precertification) is required for Synagis (palivizumab). Complete and legible precertification request form must be submitted — indicate whether this is a start of treatment (include start date) or a continuation of therapy (include date of last treatment). Include requester contact (Precertification Requested By, Phone, Fax).
- Indicate Start of treatment or Continuation of therapy with dates
- Provide Precertification Requested By name, Phone, Fax
Dosing Selection
Select dosing on the request: the form allows the standard dosing option of 15 mg/kg IM one time per month (every 30 days) or an 'Other' dosing option to be specified by the prescriber. Ensure dosing selection and planned dosing interval are documented.
- 15 mg/kg IM every 30 days (standard)
- Other — specify dosing regimen on form
Required Clinical Documentation
Clinical documentation must be submitted with all requests. Include gestational age at birth (weeks and days); number of doses already received this RSV season; whether Beyfortus was previously received this season; whether the use is for prevention of serious lower respiratory tract disease caused by RSV; prematurity status; off-season request status; and local RSV activity per CDC/NREVSS within 2 weeks of intended dose. For specific conditions (chronic lung disease of prematurity, congenital heart disease, airway/neuromuscular disorders, cystic fibrosis, immunocompromised status), provide the clinical details requested on the form (chronological age at start of RSV season, oxygen/medical support history, therapies, transplant plans, hospitalizations, nutritional status, etc.).
- Gestational age at birth (weeks and days)
- Number of doses received this RSV season
- Prior Beyfortus this season (Yes/No)
- Purpose: prevention of serious lower respiratory tract disease caused by RSV (Yes/No)
- Prematurity (≤28 weeks, 6 days) status (Yes/No)
- Off-season request (Yes/No)
- Local RSV activity per NREVSS (test type and percentage)
- Clinical details for CLD, CHD, airway/neuromuscular disorders, cystic fibrosis, immunocompromise as applicable
Administrative Information — Complete and Submit
Provide complete administrative information for the patient, prescriber, and dispensing/provider/administration site. Prescriber information must include name, credential (MD/DO/NP/PA), address, phone, fax, state license number, NPI, DEA, UPIN, provider email, office contact name and phone, and specialty. For dispensing provider/administration, indicate place of administration (physician office, outpatient infusion center, home infusion), center or agency name and phone, administration CPT code(s) if applicable, dispensing provider/pharmacy name, address, phone, fax, TIN/PIN, and whether the patient selected physician's office, retail pharmacy, specialty pharmacy or other. For the request, indicate product (Synagis), dosing choice, and whether request is for Medicare Advantage Part B (use Medicare form). Include Aetna precertification contact: Phone 1-866-752-7021 (TTY:711), FAX 1-888-267-3277.
- Prescriber: First/Last name, credential, address, city, state, ZIP, phone, fax, state license #, NPI #, DEA #, UPIN, provider e-mail, office contact name and phone, specialty selection
- Dispensing/Administration: Place of administration, center/agency name and phone, administration CPT code(s), address, dispensing provider/pharmacy name, selection of setting (physician office, retail pharmacy, specialty pharmacy, other), phone, fax, TIN/PIN
- Form-level: Indicate product (Synagis), dosing selection, Start vs Continuation dates, Medicare Advantage Part B instructions, and include precertification requester contact details and signatures as required
Fraud Warning & Acknowledgement
Any person who knowingly submits false or concealed information on the authorization request may be subject to criminal and civil penalties. The plan may request additional information or clarification to evaluate requests.
- Signature required on the request (Request Completed By and Date)
- Fraud warning: knowingly filing false information is a fraudulent insurance act subject to penalties
Background
Palivizumab (Synagis) is administered to prevent serious lower respiratory tract disease caused by RSV in high-risk infants and young children. The form collects clinical details (including gestational age at birth, prior receipt of Beyfortus, and diagnoses such as prematurity, chronic lung disease of prematurity, congenital heart disease, airway/neuromuscular disorders, cystic fibrosis, and immunocompromised status) to assess eligibility for monthly intramuscular dosing during the RSV season.
Key Definitions
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