90378
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Confirmation of RSV 'season' start using CDC NREVSS Interactive Dashboard reports or state/local health department surveillance data prior to initiating prophylaxis.
- Record of patient weight and dose calculation demonstrating monthly dose does not exceed 15 mg/kg.
- Administration records documenting number and dates of Synagis doses (to confirm ≤ 5 monthly doses per RSV season and to count hospital-administered doses toward the 5-dose maximum).
- Gestational age documentation (e.g., birth record) to confirm prematurity criteria (e.g., <29 weeks 0 days for prematurity indication; <32 weeks 0 days for CLD criteria).
Key Coverage Criteria
- Administered during RSV 'season' as defined by CDC surveillance reports (NREVSS Interactive Dashboard) or state or local health departments to confirm the start of the RSV 'season'.
- Monthly dose of Synagis does not exceed 15 mg/kg per dose.
- Dosage of Synagis does not exceed 5 monthly doses per single RSV 'season'.
- Infants in a neonatal intensive care unit who qualify for prophylaxis may receive the first dose 48 to 72 hours before discharge to home or promptly after discharge; if the first dose is administered in the hospital, it is considered the first dose of the maximum 5-dose series for the season (any subsequent hospital doses also count toward the 5-dose maximum).
- Prematurity: Infants born before 29 weeks, 0 days' gestation who are < 12 months of age at the start of the RSV 'season'.
- Chronic Lung Disease (CLD) of prematurity: Age 0 to < 12 months — preterm infants who develop CLD defined as gestational age < 32 weeks, 0 days, and a requirement for >21% oxygen for at least the first 28 days after birth (prophylaxis may be considered during the RSV season in the first year of life).
3 Active Policies
UHC-POL-synagis-palivizumab — Synagis (Palivizumab)
UMR-POL-UMR-synagis-palivizumab — Synagis (Palivizumab)
SUREST-POL-SUREST-synagis-palivizumab — Synagis (Palivizumab)
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