Synagis - BMC HealthNet Plan

3. Infants (32 weeks, 0 days through 34 weeks, 6 days) who are ≤ 3 months of age at theonset of RSV season with either of the following risk factorsa. The infant attends daycareb. The infant has a sibling younger than 5 years of age living in the samehome; multiple births younger than 1 year of age do not qualify as this riskfactor. (Up to 3 monthly doses between November 1st and March 31st willbe approved. Prophylaxis is not indicated beyond 3 months of age)OR4. Infants ≤ 12 months of age with congenital abnormalities of the airway orneuromuscular disease that compromises handling of respiratory secretions. (Up to 5monthly doses between November 1st and March 31st will be approved.)OR5. Children ≤ 2 years of age at onset of RSV season with at least one or more of thefollowing risk factors:a. Significantly compromised immune function caused by but not limited toHIV, AIDS or cancer chemotherapyb. Child has received medical treatment (e.g.: supplemental oxygen,bronchodilators, diuretics, or corticosteroid therapy) for Chronic LungDisease within 6 months of onset of the RSV season.c. Child has hemodynamically significant congenital heart disease pre orpost repair as evidenced by:– Currently receiving medication for congestive heart failure– Documented moderate to severe pulmonary hypertension– Cyanotic or acyanotic heart disease(Up to 5 monthly doses between November 1st and March 31st will beapproved)Early Onset of RSV SeasonRequests to initiate Synagis ® prophylaxis prior to November 1 st will requiredocumentation confirming an RSV outbreak in the geographic region where the memberresides.If RSV prophylaxis is initiated in October due to early onset of the RSV season in aparticular geographic area, 5 monthly doses will be covered between October 1 st and thelast day of February (in cases where the member qualifies for 5 monthly doses).This guideline provides information on BMC HealthNet Plan clinical criteria and claims adjudication processing guidelines. Theuse of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement isbased on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Planpolicies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider.Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the mostrecent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accreditingorganization guidelines and requirements, including NCQA.This document is subject to further revision in response to additional terms and requirements imposed under the Integrated CareProgram, including the ICP contract.BMCHP refers to Boston Medical Center HealthNet Plan in Massachusetts and Well Sense Health Plan in New Hampshire.Boston Medical Center HealthNet Plan and Well Sense Health Plan are trade names used by Boston Medical Center Health Plan,Inc.3 of 7BMC HealthNet Plan – Synagis ®