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RSV Prophylaxis Medical Necessity Criteria

Approved:  3/04
Reviewed:  3/06, 2/08, 1/09, 3/10, 1/13, 3/14, 1/15, 1/16, 1/17
Revised:  2/07, 2/11, 1/12, 1/15
In accordance with the recommendations of the American Academy of Pediatrics, prophylactic treatment for respiratory syncytial virus (RSV) may be considered a payable benefit under plan guidelines, for the following:
  1. Infants younger than one year with bronchopulmonary dysplasia (ie, who were born at <32 weeks gestation and required supplemental oxygen for the first 28 days after birth) and infants younger than two years with bronchopulmonary dysplasia (BPD) who required medical therapy (ie, supplemental oxygen, glucocorticoids, diuretics) within six months of the anticipated RSV season.

  2. Infants younger than one year who born at <29 weeks’ (ie, <28 weeks, 6 days) of gestation.

  3. Infants younger than one year of age with hemodynamically significant congenital heart disease.

  4. Children younger than one year of age with neuromuscular disorders that impairs the ability to clear secretions from the upper airways or pulmonary abnormalities.

  5. Children younger than two years of age who will be profoundly immunocompromised (ie, those with severe combined immunodeficiency, those younger than two years of age who have undergone lung transplantation or hematopoietic stem cell transportation) during the RSV season.

  6. Children with Down syndrome who have additional risk factors for RSV lower respiratory tract infection.

  7. The following factors may increase the risk of RSV infections (multiple factors further increase risk) and these are evaluated on an individual basis.
    • passive smoke exposure
    • day care attendance
    • two or more individuals sharing a bedroom
    • school age siblings
    • multiple births
    • severe neuromuscular disease
    • congenital abnormalities of the airways
    • low birth weight <2500 gms
    • crowded living conditions
    • family history of asthma
  8. Clinician may administer up to a maxium of 5 monthly doses of palivizumab during the RSV season to infants who qualify for prophylaxis in the first year of life. Qualifying infants born during the RSV season may require fewer doses. (ie, infants born in January would receive their last dose in March).

  9. Palivizumab prophylaxis is not recommended in the second year of life except for children who required at least 28 days of supplemental oxygen after birth and who continue to require medical intervention (supplemental oxygen, chronic corticosteroid, or diuretic therapy).

  10. Monthly prophylaxis should be discontinued in any child who experiences a breakthrough RSV hospitalization.


Utilization Management

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ConnectCare Medical Management
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