P07.36 — Preterm newborn, gestational age 33 completed weeks
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation of immunocompromised status (evidence patient will be or is profoundly immunocompromised during RSV season) for consideration of prophylaxis in immunocompromised children.
- Immunization/administration records: dates and doses given (15 mg/kg IM monthly), number of doses given to date, timing relative to regional RSV season onset and local surveillance data if applicable.
- If palivizumab administered in relation to cardiopulmonary bypass or ECMO: operative note or procedure documentation indicating cardiopulmonary bypass or ECMO and date to support consideration for post-operative dose.
- Documentation of any breakthrough RSV hospitalization (to support discontinuation of monthly prophylaxis).
Key Coverage Criteria
- Prevention of serious lower respiratory tract disease caused by RSV for up to 5 doses per RSV season when associated criteria are met for any of the following diagnoses/conditions:
- Prematurity: Member's gestational age is less than 29 weeks, 0 days AND member's chronological age at the start of RSV season is less than 12 months.
- Chronic Lung Disease (CLD) of Prematurity: Member’s gestational age is less than 32 weeks, 0 days AND requirement is for greater than 21% oxygen for at least the first 28 days after birth AND member meets either: (a) chronological age at the start of their first RSV season is less than 12 months; OR (b) chronological age at the start of the subsequent RSV season is less than 24 months AND the member continues to require medical support (e.g., chronic corticosteroids, diuretic therapy, supplement [...]
- Congenital Airway Abnormality: The condition compromises handling of respiratory secretions AND member’s chronological age at the start of RSV season is less than 12 months.
- FDA-approved: Prevention of serious lower respiratory tract disease caused by respiratory syncytial virus (RSV) in pediatric patients with a history of premature birth (less than or equal to 35 weeks gestational age) who are 6 months of age or younger at the beginning of RSV season.
- FDA-approved: Prevention of serious lower respiratory tract disease caused by RSV in pediatric patients with bronchopulmonary dysplasia (BPD) that required medical treatment within the previous 6 months and who are 24 months of age or younger at the beginning of RSV season.
2 Active Policies
AMBETTER-CP.VP.26 — Extended Ophthalmoscopy
AETNA-CPB-0318 — Palivizumab (Synagis)
Related Codes
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