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DESCRIPTIONRespiratory syncytial virus (RSV) is a virus that mainly affects the respiratory tract of children. This virus is most likely to infect children in the winter months. Some children are more at risk for getting this infection than others. For example, children who are born prematurely may be at higher risk for getting an infection with this virus during their first year of life. Another high risk group includes patients with chronic lung disease (CLD).
Palivizumab (Synagis®) a monoclonal antibody, is an intramuscular injection developed to protect high risk infants against the worst effects of respiratory synctial virus, the most common cause of lower respiratory infections such as bronchitis and pneumonia in infancy and early childhood. Synagis® is a genetically engineered antibody against the RSV virus. It is manufactured using human and mouse antibody genes (produced by recombinant DNA technology). Over 125,000 children in the United States are hospitalized each year due to RSV and approximately 500 die. (revised 10-28-2005)
FDA APPROVED INDICATIONS
Palivizumab (Synagis®) is indicated for the prevention of serious lower respiratory tract disease caused by RSV in pediatric patients at high risk of RSV disease. Safety and efficacy were established in infants less than 24 months of age with bronchopulmonary dysplasia (BPD) and infants with a history of prematurity (35 weeks or less gestational age). (added 9-30-2004) Palivizumab (Synagis®) is also approved for children with hemodynamically significant congenital heart disease. (revised 10-28-2005)
POLICYPrior authorization is required.
Palivizumab (Synagis®) is considered medically necessary only during RSV season (October 31 - March 31) for the following indications:
Patients less than 2 years of age at the start of RSV season meeting the following criteria:
Infants with a history of prematurity <35 weeks meeting the following criteria:
Infants 24 months of age or less with hemodynamically significant cyanotic or acyanotic congenital heart disease. (Maximum of 5 doses/season)
If one of the above indications is not present, palivizumab (Synagis®) is considered not medically necessary for the following indications:
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY8/1998: RSV policy approved by Medical Policy Advisory Committee (MPAC)
11/1998: Synagis® criteria approved by MPAC; policy merged with RSV and renamed
2/2/2001: Entire "Policy Section" revised
10/26/2001: Infants < 28 weeks of gestation up to 12 months of age "at the start of RSV season" added
1/30/2002: Above statement added to Infants 29-32 weeks and 32-35 weeks
2/14/2002: Investigational definition added
5/2/2002: Type of Service and Place of Service deleted
5/28/2002: Code Reference section updated, CPT 86756 added
11/6/2002: Nova Factor new telephone and fax numbers added. Telephone # 1-800-235-8498 and fax # 1-888-355-6652 deleted.
9/17/2004: Code Reference section updated, CPT 86756, 90780, 90781, 90782 deleted, ICD-9 diagnosis code 460.0 invalid and deleted, ICD-9 diagnosis code range 460-466.0, 478.8-480.0, 493.0-493.1, 765.00-765.19, 770.0-770.9 listed separately, ICD-9 diagnosis code range 493.0-493.1 5th digit added, HCPCS J1565 description revised, HCPCS S9562 added
9/30/2004: Code Reference section updated, ICD-9 diagnosis code 745.10, 745.11, 745.2, 745.4, 745.5, 745.60, 745.61, 745.69, 745.8, 746.02, 746.2, 746.7, 746.81, 746.83, 747.0, 747.10, 747.3, 747.49 added covered codes
10/28/2005: Description section updated. FDA approved indications revised. Policy section updated: changed preferred provider to Accredo, changed telephone # from 1-866-591-9075 to 1-866-240-3373, changed fax # from 1-866-591-9094 to 1-877-369-3447. Sources updated; American Academy of Pediatrics Web Site, Synagis® and RespiGam® added
11/4/2005: Code Reference section updated, ICD9 diagnosis codes 491.00-491.02, 491.20-491.22, 491.9, 493.20-493.22, 496, 765.20-765.27, V46.2 added; ICD9 procedure code 99.29 added.
11/2005: Approved by Pharmacy & Therapeutics (P & T) Committee
2/7/2006: Code Reference table updated: The notes under CPT codes 90378 and 90379 and HCPCS code J1565 were updated to include the new intramuscular and IV infusion administration codes (90772, 90765-90766); ICD9 diagnosis codes 079.6, 079.89, 460.0-466.0, 466.11, 478.8-478.9, 480.0-480.9, 487.1, 519.8, 769, 770.0-770.9, 786.9 deleted, V58.65 added
8/22/2006: Respigam deleted from policy due to discontinuation of medication.
11/14/2006: Code Reference section updated: ICD-9 code V04.82 added
1/12/2006: Code reference section updated. ICD-9 codes 491.00, 491.01, and 491.02 deleted. ICD-9 codes 491.0 and 491.1 added.
01/01/2009: Accredo preferred provider information removed. BCBSMS information added.
8/17/2009: Policy updated: off label uses deleted. Policy statement section updated: deleted RSV season changed from September-March to October-February. Maximum of 5 doses/season added to infant age specifications. Infant age specifications revised.
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions.
08/21/2013: Policy revised to change the RSV season from October - February to October 31 - March 31. Deleted procedure codes J1565 and 90379 from the Code Reference section.
08/28/2015: Code Reference section updated for ICD-10.
05/31/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions.
SOURCE(S)A search of the literature was completed through the MEDLINE database. The search strategy focused on references containing the following words:
Clinical Pharmacology Online, 1998
FDA Web Site
FDA labeling, based on data submitted to the Food and Drug Administration
Groothuis Jr. 1993, NEJM 329: 1524-30
Ellenberg SS, 1994 NEJM 331: 203-4
The Impact-RSV Study Group. Pediatrics 1998;102:531-37.
American Academy of Pediatrics. Policy Statement: Prevention of Respiratory Syncytial Virus Infections: Indications for the Use of Palivizumab and Update on the Use of RSV-IGIV. November 1998, pp. 1211-1216.
American Academy of Pediatrics. Respiratory syncytial virus immune globulin intravenous: Indications for use. Pediatrics 1997;99:645-50.
American Academy of Pediatrics, Committee on Infectious Diseases and Committee on Fetus and Newborn. Revised Indications for the Use of Palivizumab and Respiratory Syncytial Virus Immune Globulin Intravenous for the Prevention of Respiratory Syncytial Virus Infections. Pediatrics.2003; 112:1442-1446. (added 9-30-2004)
American Academy of Pediatrics Web Site (added 10-28-2005)
Synagis® Prescribing Information (added 10-28-2005)
RespiGam® Prescribing Information (added 10-28-2005)
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.