CurrentHighmark Blueshield NenyPolicy N/A

Outpatient Synagis (palivizumab) authorization

This document is an outpatient medical injectable authorization request form used by providers to request coverage of Synagis (palivizumab) for infants through Highmark BlueShield (Medical Benefit only). It affects prescribing physicians, specialty pharmacies, and facility billing staff submitting authorization for RSV prophylaxis.

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient Synagis (palivizumab) authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed Synagis authorization form to Highmark at 1-833-619-5745 and verify member eligibility and benefits prior to dispensing or administration.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Max 5per local RSV season dose limit

≤12 mo; 12–24 mocovered age categories listed on form

Fax 1-833-619-5745submission fax number

90378Synagis procedure code referenced

Coverage Criteria for Synagis (palivizumab)

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Initial and season dosing eligibility

Covered when the infant meets the applicable age category and at least one of the high‑risk clinical conditions listed below:

Age and clinical risk

AND at least one high‑risk condition
- Preterm birth < 29 weeks 0 days gestation
- Preterm birth < 32 weeks 0 days gestation with chronic lung disease (CLD)
- Infant with chronic lung disease of prematurity that continues to require medical support (eg, supplemental oxygen, chronic corticosteroids, diuretic therapy)
- Infant is profoundly immunocompromised during the RSV season
- Infant is undergoing a cardiac transplant
- Infant with cystic fibrosis with evidence of severe lung disease or nutritional compromise (eg, prior hospitalization for pulmonary exacerbation, abnormal imaging)
- Infant with hemodynamically significant congenital heart disease (eg, receiving medication to control congestive heart failure and/or requiring cardiac surgical procedures; low weight/length percentile; moderate to severe pulmonary hypertension)
- Infant born with congenital airway abnormalities
- Infant born with a neuromuscular condition that compromises handling of respiratory secretions

Requests that would result in more than 5 doses within the local RSV season are not compliant with the form's stated limits. The form explicitly notes a 'Maximum of 5 doses within the local RSV season' beside the field for 'Number of doses requested' and asks providers to document the 'Number of doses infant has already received during current RSV season' to ensure this threshold is not exceeded.

The authorization form does not include explicit statements labeled 'Not Medically Necessary' (NMN). However, the form requires documentation of prior doses and the number of doses requested; absence of required clinical details or requests that would exceed the maximum of 5 doses may lead to a determination that authorization is not appropriate. Providers are therefore instructed to verify member eligibility and supply the requested dosing history and supporting clinical information to avoid denial or delay.

Provider Actions, Submission and Documentation Requirements

Prior Authorization

Prior Authorization and Eligibility Verification

Providers must fax the completed Synagis authorization form to Highmark at 1-833-619-5745 and verify member eligibility and benefits prior to submission.

Prior authorization form must be completed and faxed
Confirm eligibility/benefits before submitting request

Note

Dispensing Pathways and Routing

The form differentiates dispensing pathways. Select the appropriate pathway and route the request accordingly: Specialty Pharmacy for home infusion, office professional, or ambulatory infusion suite professional; or Buy & Bill for office professional or outpatient hospital administration.

Specialty Pharmacy — for Home Infusion, Office Professional, or Ambulatory Infusion Suite Professional
Buy & Bill — for Office Professional or Outpatient Hospital administration
Verify dispensing route and send referral/prescription to dispensing pharmacy when applicable

Documentation Required

Required Clinical Attachments

Attach all pertinent clinical information to the submission to support medical necessity (gestational age, birth weight, current age and weight, oxygen requirements, history of lung or heart disease, prior hospitalizations, transplant status, or other relevant clinical notes). Incomplete forms or missing clinical attachments may result in denial or delayed authorization; providers are instructed to include all necessary documentation.

Include documentation of gestational age and birth weight
Current age and current weight with date of weight
Oxygen requirements and days after birth when oxygen given
Relevant history (e.g., CLD, congenital heart disease, transplant, hospitalizations)

Billing Rule

Prescribing Details and Dose Limits

Include prescribing details with the request: procedure code CPT 90378 (Synagis), gestational age at birth, birth weight, current weight and age, number of doses already received during the current RSV season (NICU and non‑NICU doses), and number of doses requested. Requests exceeding the maximum of 5 doses within the local RSV season may be denied.

CPT code: 90378
Document gestational age, birth weight, current age and weight, and date of current weight
Number of doses infant has already received during current RSV season (NICU and non‑NICU doses)
Number of doses requested (note: maximum of 5 doses per local RSV season)

Denial Risk

Incomplete Submission Risk

Incomplete forms or missing pertinent clinical attachments may result in denial or delayed authorization. Providers should verify all required fields are completed on the form and attach supporting clinical documentation before faxing to avoid delays.

Ensure form is fully completed prior to faxing
Attach all requested clinical documentation (see Required Clinical Attachments)
Verify member eligibility and benefits before submission

Key Clinical Definitions

Hemodynamically significant congenital heart disease

Core definitionInfant with hemodynamically significant congenital heart disease defined by need for medication to control congestive heart failure, and/or requirement for cardiac surgical procedures

Additional qualifiersPresence of cyanotic heart disease qualifies as hemodynamically significant

Growth/weight qualifierWeight or length less than the 10th percentile is a qualifying factor

Pulmonary hypertensionModerate to severe pulmonary hypertension qualifies the infant

Chronic lung disease of prematurity (CLD)

Core definitionInfant with chronic lung disease of prematurity (CLD) is defined as a history of CLD that continues to require medical support following preterm birth

Types of medical support listedSupplemental oxygen, chronic corticosteroids, or diuretic therapy

Documentation requiredAttach pertinent clinical information documenting oxygen requirements and supportive therapies

OpenPayer

Outpatient Synagis (palivizumab) authorization

Coverage Criteria for Synagis (palivizumab)

Coding and Dose Limits

Provider Actions, Submission and Documentation Requirements

Key Clinical Definitions

Background