BlueCross BlueShield of Tennessee Medical Policy Manual

Palivizumab

DESCRIPTION

Palivizumab is a humanized monoclonal antibody (IgG1k) produced by recombinant DNA technology. It is supplied as a sterile lyophilized product; thus, it is a passive immunizing agent.

An example of a preparation of palivizumab is Synagis®.

The American Academy of Pediatrics (AAP) states, The current recommendations for  infants born between 32 and 35 weeks of gestation (i.e., defined as 32 weeks, 0 days, through 34 weeks, 6 days) are intended to reduce the risk of respiratory syncytial virus (RSV) hospitalizations during the period of greatest risk among infants with consistently identified risk factors. The AAP recommends the following preventative measures regarding high-risk infants:

REFER TO DECISION SUPPORT TREE

POLICY

MEDICAL APPROPRIATENESS

APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS

BlueCross BlueShield of Tennessee’s Medical Policy complies withTennessee Code Annotated Section 56-7-2352 regarding coverage of off-label indications of Food and Drug Administration (FDA) approved drugs when the off-label use is recognized in one of the statutorily recognized standard reference compendia or in the published peer-reviewed medical literature.

IMPORTANT REMINDER

We develop Medical Policies to provide guidance to Members and Providers.  This Medical Policy relates only to the services or supplies described in it.  The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy.  For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed.  If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.

ADDITIONAL INFORMATION  

For appropriate dosage information, contraindications, precautions, warnings, and monitoring information, please refer to one of the standard reference compendia (e.g., The American Hospital Formulary Service Drug Information).

There is insufficient evidence supporting the use of palivizumab for the prevention of other conditions/diseases.

RSV prophylaxis should be initiated just before the onset of the RSV season and terminated at the end of the RSV season. In most seasons and in most areas of the United States, the first dose should be administered at the beginning of November and the last dose should be administered at the beginning of March. The onset of RSV infection occurs earlier in southern states. Practitioners should contact their health departments and/or diagnostic virology laboratories in their geographic areas to determine the optimal time to begin administration.

No evidence was found to support the year round administration of RSV prophylaxis.

Children, who still require prophylaxis, should be considered for a postoperative dose of palivizumab, when medically stable after surgical procedures that use cardiopulmonary bypass.

Infants or children who are receiving immunoprophylaxis and experience a breakthrough RSV infection, prophylaxis should continue until a maximum of 3 doses have been administered to infants in the 32 to less than 35 weeks (defined as 32 weeks, 0 days, through 34 weeks, 6 days) gestation group or until a maximum of 5 doses for infants with congenital heart disease, CLD, congenital abnormalities of the airway, severe neuromuscular disease, or preterm birth before 32 weeks’ gestation.

American Academy of Pediatrics recommends that the following infants and children are not at increased risk from RSV and generally should not receive RSV immunoprophylaxis:

Center for Disease Control and Prevention recommended preventative measures:

SOURCES

American Academy of Pediatrics. (2009, September). Policy statement modified recommendations for use of palivizumab for prevention of respiratory syncytial virus infections. Retrieved July 21, 2010 from  http://pediatrics.aappublications.org/cgi/reprint/peds.2009-2345v1?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=palivizumab&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT.

BlueCross BlueShield Association. Medical Policy Reference Manual. (10:2010). Immune prophylaxis for respiratory syncytial virus (5.01.10). Retrieved October 24, 2011 from BlueWeb.

Center for Disease Control and Prevention. (2010, January). Respiratory syncytial virus:  transmission and prevention.  Retrieved October 24, 2011 from http://www.cdc.gov/rsv/about/transmission.html.

Lexi-Comp Online. (2011). AHFS DI. Palivizumab. Retrieved October 19, 2011 from Lexi-Comp Online with AHFS.

MICROMEDEX Healthcare Series. Drugdex Drug Evaluations. (2011). Palivizumab. Retrieved October 19, 2011 from MICROMEDEX Healthcare Series.

Pickering L. K., Baker C. J., Kimberlin, D. W., Long, S. S. (2009). Respiratory Syncytial Virus. In American Academy of Pediatrics: Red Book: 2009 Report of the Committee on Infectious Diseases (28th ed., pp. 560-569). Elk Grove Village, IL: American Academy of Pediatrics.

MedImmune, LLC. (2011, April). Synagis® (palivizumab) for intramuscular administration. Retrieved October 19, 2011 from http://www.medimmune.com/pdf/products/synagis_pi.pdf.

ORIGINAL EFFECTIVE DATE: 12/4/1997

MOST RECENT REVIEW DATE:  12/2/2011

ID_BT

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

Pharmaceutical Decision Support Tree

Palivizumab (Synagis®)

  1. Is the agent being used for the prevention of serious lower respiratory tract infection caused by respiratory syncytial virus (RSV)?

If yes, go to question #2

If no, this does not meet medical necessity and/or medical appropriateness criteria

  1. Is the agent being used in an infant less than 6 months of age who was born at 29 weeks - 31 weeks, 6 days gestation?

If yes, approve for up to a maximum of five months of therapy, but no later than March 31st

If no, go to question #3

  1. Is the agent being used in an infant less than 35 weeks gestation with congenital abnormalities of the airway, or severe neuromuscular disease with ALL of the following?

If yes, approve for up to a maximum of five months of therapy, but no later than March 31st

If no, go to question #4

  1. Is the agent being used in an infant less than 12 months of age with evidence of ALL the following?

If yes, approve for up to a maximum of five months of therapy, but no later than March 31st

If no, go to question #5

  1. Is the agent being used in an infant or child less than 24 months of age with chronic lung disease (CLD) who has received medical therapy (e.g., oxygen, diuretics, corticosteroids, mechanical ventilation, or bronchodilators) for CLD within the previous 6 months?

If yes, approve for up to a maximum of five months of therapy, but no later than March 31st

If no, go to question #6

  1. Is the agent being used in an infant or child less than 24 months of age with hemodynamically significant congenital heart disease (e.g., moderate severe pulmonary hypertension, receiving medication to control congestive heart failure, acyanotic heart disease or cyanotic heart disease)?

(NOTE: The AAP states the following are not at increased risk: “Infants and children with hemodynamically insignificant heart disease [e.g., secundum atrial septal defect, small ventricular septal defect, pulmonic stenosis, uncomplicated aortic stenosis, mild coarctation of the aorta, and patent ductus arteriosus])”

If yes, approve for up to a maximum of five months of therapy, but no later than March 31st

If no, go to question #7

  1. Is the agent being used in an infant 32-35 weeks gestation (i.e., defined as 32 weeks, 0 days through 34 weeks, 6 days) who was born less than 3 months before the onset of RSV season (August 1 through October 31) or during the current RSV season (November 1 through March 31) with ANY ONE of the following risk factors?

If yes, approve for up to a maximum of 3 doses, but no later than March 31st

(Note: The AAP states this category should receive prophylaxis until they reach 3 months of age so they may only need 1 or 2 doses until they reach 3 months of age)

If no, this does not meet medical necessity and/or medical appropriateness

This document has been classified as public information.