Policy Update: CAM 50110 Immune Prophylaxis for Respiratory Syncytial Virus

Policy Update: CAM 50110 Immune Prophylaxis for Respiratory Syncytial Virus


We have revised our policy regarding Synagis® (palivizumab). We changed the policy based on recent recommendations for use of Synagis® by the American Academy of Pediatrics (AAP). The AAP is an independent company that provides health education information on behalf of BlueCross BlueShield of South Carolina and BlueChoice HealthPlan. We may consider monthly administration of immune prophylaxis for respiratory syncytial virus (RSV) during the RSV season with palivizumab medically necessary for infants and children. This is in accordance with updated 2014 guidelines from AAP. This policy does not address the treatment of RSV.

What you need to know:

  • Coverage will be available beginning October 15, 2014, and extend through March 31, 2015. We will deny any claims you file for dates of service between April 1, 2014, and October 14, 2014.
  • We require prior authorizations for Synagis®. We will deny claims you file with no prior authorizations. To request prior authorization or precertification for Synagis, please follow the appropriate procedures for your patient’s coverage and billing method.
  • We recognize procedure code 90378 for this service.

Things to tell your patients:

  • RSV is a common cause of lower respiratory infections in children, particularly those less than 2 years old with prematurity, chronic lung disease (formerly known as bronchopulmonary dysplasia), congenital heart disease or multiple congenital anomalies.
  • Remind parents about the importance of careful hand hygiene to lower chances of RSV infection.
  • All high-risk infants 6 months of age and older and their contacts should receive an influenza vaccine, as well as other recommended age-appropriate immunizations.


    You can read CAM 50110 in its entirety on our medical policies and clinical guidelines page at http://web.southcarolinablues.com/providers/educationcenter/medicalpoliciesandclinicalguidelines.aspx 

    Questions about this bulletin? Please contact Provider Education at provider.education@bcbssc.com or by calling 803-264-4730.