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Massachusetts Standard Form for Synagis® Prior Authorization Requests

A standardized Massachusetts prior authorization request form for Synagis® (palivizumab) used by participating health plans (example: Tufts Health Plan) to collect patient, prescriber, and clinical information needed to evaluate medical necessity based on AAP 2014 criteria and plan-specific coverage policies. It supports initial and reauthorization requests and professional administration (buy-and-bill).

Policy Summary

Payerharvard pilgrim health care

PolicyMassachusetts Standard Form for Synagis® Prior Authorization Requests

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProviders must complete and submit this Massachusetts Synagis prior authorization form (or online prior auth via provided URL) with required clinical details, signatures, dates, number of doses requested, and supporting clinical notes to the plan's Pharmacy Utilization Management Department or fax number.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

MultipleCovered Indications (by category)

Form-basedAuthorization Process

AAP 2014Clinical Guideline Source

Coverage summary

This is a Massachusetts standardized Synagis® (palivizumab) prior authorization form used by participating health plans (example: Tufts Health Plan) to collect patient, prescriber, demographic, clinical, and administrative information needed to evaluate medical necessity based on AAP 2014 guidance. The form supports initial and reauthorization requests and professionally administered (buy-and-bill) delivery.

Form-based prior authorization is required: providers must complete and submit this Massachusetts Synagis prior authorization form (or use the online prior authorization portal) with required clinical details, signatures, dates, number of doses requested, and supporting clinical notes to the plan's Pharmacy Utilization Management Department or fax number. Some plans may not accept this form for Medicare or Medicaid requests.

Medical-necessity criteria (AAP 2014-based)

Clinical eligibility (based on 2014 AAP Committee on Infectious Disease and Bronchiolitis Guidelines)

Request should document that ALL applicable patient attributes below are met for the selected condition:

Chronic Lung Disease (CLD) / Bronchopulmonary Dysplasia / Chronic respiratory disease

CLD specific criteria
- CLD definition: CLD of prematurity defined as gestational age ≤31 weeks, 6 days≤31 weeks, 6 days
- Oxygen requirement: Requirement for 21% oxygen for at least the first 28 days after birth21% oxygen for ≥28 days
- Age-based CLD eligibility
  - Age <12 months with CLD: Age <12 months at start of season with CLD<12 months
  - Age 12-24 months with CLD and ongoing support: 12-24 months of age with CLD AND continues to require medical support during the 6-month period before second RSV season12-24 months
    Must document continued medical support during 6-month period before second RSV season and supplemental therapies (oxygen, diuretics, chronic corticosteroids)

Chronic Respiratory Disease arising in the perinatal period

Wilson-Mikity Syndrome (P27.0)P27.0
Bronchopulmonary Dysplasia perinatal: Bronchopulmonary Dysplasia originating in the perinatal period (P27.1)P27.1
Other chronic respiratory disease perinatal: Other chronic respiratory disease originating in the perinatal period (P27.8)P27.8

Congenital Heart Disease (CHD)

Hemodynamically significant CHD - <12 months: <12 months of age at start of season with hemodynamically significant CHD (examples listed)<12 months
Examples include: acyanotic heart disease receiving medication to control congestive heart failure and surgery to correct (document drugs/dates and surgery date); moderate to severe pulmonary hypertension; cyanotic heart disease (document diagnosis). Provide surgery dates where applicable.
Cardiac transplant 12-24 months: 12-24 months of age undergoing cardiac transplant during RSV season12-24 months
Provide planned surgery date to support eligibility.

Airway / Neuromuscular conditions

Compromised handling of secretions - age requirement: <12 months of age at start of season and compromised handling of secretions<12 months
Due to significant abnormality of the airway or neuromuscular condition; attach clinical notes.
Significant airway abnormality: Significant abnormality of the airway (attach clinical notes)
Attach clinical notes.
Neuromuscular condition (attach clinical notes)
Attach clinical notes.

Prematurity

Gestational age cutoff: Gestational age ≤28 weeks, 6 days≤28 weeks, 6 days
Age at season start: Age <12 months at start of season<12 months

Other medical conditions / high-risk diagnoses

Cystic Fibrosis
Down's Syndrome
Immunocompromised
Document specifics
Other relevant medical history
Describe other relevant medical history

Provider actions and documentation requirements

Prior Authorization

Submit completed Synagis prior authorization form

Complete and submit the Massachusetts Synagis prior authorization form or use the online prior authorization portal. Include the completed form, required clinical details, signatures, dates, number of doses requested, and any supporting clinical notes. Send to the plan's Pharmacy Utilization Management Department or fax the form to the plan's fax number.

Mail/Attn: Pharmacy Utilization Management Department (Tufts Health Plan)
Fax: 1 . 617 . 673 . 0988
Online prior authorization: https://point32health.promptpa.com

Documentation Required

Document gestational age, weights, oxygen and therapies

Document the key perinatal and current clinical data on the form and attach supporting clinical notes as indicated.

Gestational age (weeks and days)
Birth weight
Current weight and date current weight recorded
Dates of oxygen supplementation (supplemental oxygen dates)
Diuretic therapy (drugs and dates)
Chronic corticosteroid therapy (drugs and dates)
Attach clinical notes for significant airway abnormality or neuromuscular condition

Prior Authorization

Indicate if request is for reauthorization

Indicate on the form whether the request is for reauthorization and provide the treatment timeline and dosing history.

Start and end dates of therapy
Date of last dose received
Number of doses received to date
Number of doses requested

Billing Rule

Provide billing provider and service details for buy-and-bill

For professionally administered medications or buy-and-bill requests, provide the servicing and billing provider and service details on the form.

Servicing prescriber/facility name (and indicate if same as prescribing clinician)
Servicing provider NPI/Tax ID
Billing provider name and billing provider NPI
CPT code and J-code
Number of units / # of visits

Documentation Required

Attach surgery or transplant dates where applicable

When eligibility is related to CHD surgery or planned cardiac transplant, attach the surgery date(s) or planned transplant date to support the request.

Date(s) of corrective cardiac surgery (if already performed)
Planned cardiac transplant date (if applicable)

Background

This standardized prior authorization form collects demographic, clinical, and administrative data necessary to determine medical necessity for Synagis consistent with AAP 2014 Committee on Infectious Disease and Bronchiolitis guidance. It lists pediatric high-risk categories and the specific data elements to document eligibility (for example gestational age, birth weight, current weight/date, oxygen supplementation dates, diuretic or chronic corticosteroid therapy, ICD codes such as P27.0/P27.1/P27.8 for chronic respiratory disease arising in the perinatal period, and details of CHD or airway/neuromuscular conditions).

Providers must indicate whether the request is for reauthorization and provide start/end dates, date of last dose, number of doses received and requested, and include billing details for professionally administered medications (CPT and J-code fields, servicing prescriber/facility name, NPI/Tax ID, billing provider name and NPI).

Definitions

CLD of prematurityDefined here as gestational age ≤31 weeks, 6 days and requirement for 21% oxygen for at least the first 28 days after birth

CPT (field)	CPT code for service to be provided (enter appropriate code)
J-code (field)	J-code for palivizumab (e.g., J code for palivizumab to be entered by provider)

OpenPayer

Massachusetts Standard Form for Synagis® Prior Authorization Requests

Coverage summary

Medical-necessity criteria (AAP 2014-based)

Provider actions and documentation requirements

Codes referenced on form

Background

Revision history

P27.0	Wilson-Mikity syndrome
P27.1	Bronchopulmonary dysplasia originating in the perinatal period
P27.8	Other chronic respiratory disease originating in the perinatal period