Guideline for Prophylaxis of Respiratory Syncytial Virus (RSV) Infections in High-Risk Infants and Children
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Guideline governing coverage and prior authorization of palivizumab for prevention of RSV infection in high-risk infants and children under Hawaii Medicaid QUEST Integration for the 2016-2017 RSV season.
No material clinical or coverage changes in this revision.
Coverage Criteria for Palivizumab (RSV Prophylaxis)
Initial eligibility criteria
Covered when ALL of the following are met for each criteria group as specified below
Group A: Infants <12 months at season start
- High-risk conditions for <12 months: a. Hemodynamically significant congenital heart disease and/or persistent pulmonary hypertension requiring medical management; b. Born <29 weeks gestation (28+6 or less); c. Pulmonary abnormalities or neuromuscular disease impairing secretion clearance from the upper or lower airways; d. Born <32 weeks (31+6 or less) with history of requiring supplemental oxygen or positive pressure ventilation for the first 28 days after birth.
Group B: Children <24 months at season start
- High-risk conditions for <24 months: a. Chronic Lung Disease (CLD) requiring medical management, defined as need for supplemental oxygen, chronic corticosteroid use, or diuretic therapy during the 6-month period prior to the current RSV season; b. Severely immunocompromised patients (e.g., those who undergo stem cell transplantation, are receiving chemotherapy, or have a severe immunocompromised condition).
The following pediatric patients are excluded from coverage for palivizumab: infants and children with hemodynamically insignificant heart disease (examples include secundum atrial septal defect, small ventricular septal defect, mild coarctation, and patent ductus arteriosus). Also excluded are patients with cardiac lesions that have been adequately corrected by surgery unless they continue to require medication or supplemental oxygen for their heart disease, and children with mild cardiomyopathy not requiring medical therapy.
Palivizumab is not indicated for treatment of active RSV infection. If a patient develops RSV infection during the current RSV season, palivizumab should be discontinued, and use for that patient during the season is not covered.
Billing and Coding
| affected codes | Placeholder — document references prior authorization for palivizumab but does not list specific billing codes. |
Provider Actions and Prior Authorization
Prior authorization required
Prior authorization is required for palivizumab; approvals will cover doses given at 28–35 day intervals during the RSV season (September 1, 2016 through March 31, 2017).
Authorization covers 28–35 day dosing intervals
Authorized coverage explicitly applies to palivizumab dosing intervals of 28–35 days; the policy does not specify any additional step-therapy sequencing.
How to submit prior authorization
Submit prior authorization requests on the Standardized Prior Authorization (PA) Form; requests for patients on the Koan SHOTT transplant program should be faxed to 1-888-335-8474. PA requests may also be obtained from the member's QI health plan.
Not covered for active or documented RSV infection
Palivizumab is not covered for patients with active RSV infection or for those with a documented history of RSV infection during the current RSV season; it is indicated for prevention, not treatment, and should be discontinued if RSV infection occurs.
Definitions and Season Dates
Background
Respiratory syncytial virus (RSV) is a common cause of serious lower respiratory tract disease in high‑risk infants and young children. Palivizumab (Synagis®) is a monoclonal antibody administered for prophylaxis to prevent RSV infection in selected high‑risk pediatric patients. This policy limits use to prevention — it does not authorize use for active RSV disease — and excludes certain low‑risk cardiac conditions and patients whose cardiac lesions are surgically corrected without ongoing medical or oxygen needs.
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