CurrentBaylor Scott & White Health PlanPolicy 305

Nirsevimab-alip (Beyfortus) for RSV prophylaxis

Defines medical necessity and prior authorization requirements for use of nirsevimab-alip (Beyfortus) for prevention of RSV in infants and young children for Baylor Scott & White Health Plan members during RSV season.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyNirsevimab-alip (Beyfortus) for RSV prophylaxis

Policy CodePolicy 305

Change TypeNo material change

Effective DateNov 1, 2025

Next Review DateSep 8, 2026

Key ActionObtain prior authorization and document CDC/ACIP eligibility and number of palivizumab doses (must be fewer than five in current RSV season).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

PA requiredadministrative requirement

<8m; 8–19m at riskage groups covered

<5palivizumab dose limit

305internal id

TX HB154Medicaid note

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Medical necessity criteria

Covered when ALL of the following are met:

Overall: Member meets CDC/ACIP recommendations for nirsevimab (Beyfortus) AND has received fewer than five doses of palivizumab (Synagis) in the current RSV season.palivizumab <5 doses

See CDC/ACIP age- and risk-based subcriteria below.

CDC/ACIP age/risk criteria (first or second RSV season): One of the following: (a) younger than 8 months born during or entering first RSV season and meets at least one subcondition; OR (b) 8 to 19 months entering second RSV season with increased risk for severe RSV disease as defined below; OR (c) undergoing cardiac surgery with cardiopulmonary bypass during or entering first or second RSV season eligible for an additional post‑surgery dose.

Subcriteria mirror CDC/ACIP guidance.

Subcriteria for members younger than 8 months (first RSV season)

At least one of: i. Pregnant parent did not receive RSVpreF vaccine; OR ii. Pregnant parent's RSVpreF vaccination status is unknown; OR iii. Born <14 days after the pregnant parent's RSVpreF vaccination; OR iv. Born to pregnant people who might not have mounted an adequate immune response to vaccination (e.g., immunocompromising conditions) or who have conditions associated with reduced transplacental antibody transfer (e.g., living with HIV); OR v. Experienced loss of transplacentally acquired antibodies (e.g., cardiopulmonary bypass or extracorporeal membrane oxygenation); OR vi. Substantially increased risk for severe RSV disease (e.g., hemodynamically significant congenital heart disease or need for intensive care with oxygen at hospital discharge).

Subcriteria for members 8 to 19 months entering second RSV season

At least one of: i. Born prematurely and have chronic lung disease of prematurity requiring medical support (e.g., chronic corticosteroid therapy, diuretic therapy, or supplemental oxygen) any time during the 6‑month period before start of the second RSV season; OR ii. Severe immunocompromise; OR iii. Cystic fibrosis with weight‑for‑length <10th percentile or manifestation of severe lung disease (e.g., prior hospitalization for pulmonary exacerbation in first year of life or persistent abnormalities on chest imaging when stable); OR iv. American Indian or Alaska Native children.

Subcriteria for cardiac surgery: Member undergoing cardiac surgery with cardiopulmonary bypass during or entering their first or second RSV season is eligible for an additional dose of nirsevimab after surgery.

Coverage of nirsevimab‑alip (Beyfortus™) is subject to the member’s specific benefit plan. Providers must review the member’s Evidence of Coverage (EOC) / Summary Plan Description (SPD) and any applicable federal or state rules to confirm benefit availability and limitations before rendering services.

Use of nirsevimab is not considered within the policy’s eligibility when the member has already received five or more doses of palivizumab (Synagis®) in the current RSV season. Members who have reached this threshold should not be approved for nirsevimab under this policy.

Billing and Code Sets

CPT CodesCPT

90380	Respiratory syncytial virus, monoclonal antibody, seasonal dose; 0.5 mL dosage, for intramuscular use
90381	Respiratory syncytial virus, monoclonal antibody, seasonal dose; 1 mL dosage, for intramuscular use

HCPCS CodesHCPCS

No codes listed

ICD10 codesICD-10

No codes listed

ICD10 Not coveredICD-10Not Covered

No codes listed

Palivizumab dose threshold (current RSV season) - inv-08

Palivizumab dose limitMember must have received fewer than five doses of palivizumab (Synagis®) in the current RSV season

ApplicabilityThreshold applies to eligibility for nirsevimab (Beyfortus) prophylaxis during the current RSV season

Not medically necessary when exceededUse of nirsevimab when a member has received five or more doses of palivizumab in the current RSV season is outside stated eligibility

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization required for nirsevimab-alip (Beyfortus™). Providers must obtain prior authorization before administration. Review the member's Evidence of Coverage/Summary Plan Description for plan-specific requirements. For Medicare and Medicaid plans, follow applicable NCD/LCD or Texas Medicaid TMPPM and mandates (eg, HB154) as applicable.

Policy Number: 305
Effective Date: 11/01/2025

Note

Substitution Guidance — palivizumab

If nirsevimab (Beyfortus™) is unavailable or not feasible to administer, substitute with palivizumab (Synagis®) per AAP recommendations for high-risk infants. Providers should follow the American Academy of Pediatrics (AAP) guidance on palivizumab dosing and eligibility until nirsevimab becomes available.

Substitute: palivizumab (Synagis®) per AAP guidance

Documentation Required

Documentation Requirements

Document that the patient meets CDC/ACIP recommendations for nirsevimab (Beyfortus™) and record the specific criterion met (see CDC/ACIP immunization schedules). Include documentation of palivizumab doses received in the current RSV season (number of doses, dates administered) and any relevant clinical rationale (eg, prematurity, immunocompromise, cardiopulmonary bypass). Maintain copies of supporting records for prior authorization review.

Document CDC/ACIP criteria met (eg, age and risk category)
Record number and dates of palivizumab doses in current RSV season
Retain clinical notes supporting eligibility (eg, prematurity, immunocompromise, cardiac surgery)

Denial Risk

Prior Authorization Consequence

Failure to obtain required prior authorization may result in denial of payment. Providers are expected to follow interim CDC/ACIP recommendations during periods of limited nirsevimab availability and to ensure prior authorization reflects any applicable interim guidance.

Denial risk if PA not obtained
Apply interim CDC/ACIP recommendations when applicable

OpenPayer

Nirsevimab-alip (Beyfortus) for RSV prophylaxis

Coverage / Medical Necessity Criteria

Billing and Code Sets

Provider Requirements and Prior Authorization

Clinical Background

Definitions