Does P07.26 require prior authorization?

No, P07.26 does not require prior authorization (high confidence). Covered without prior authorization.

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`P07.26`, Extreme immaturity of newborn, gestational age 27 completed weeks

ICD-10-CM

Prior Authorization

No Prior Auth Required

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.

3 Active Policies

AMBETTER-CP.VP.26, Extended Ophthalmoscopy

AETNA-CPB-0318, Palivizumab (Synagis)

AETNA-CPB-0579, T-Wave Alternans

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P07.26, Extreme immaturity of newborn, gestational age 27 completed weeks