Nebraska Medicaid Respiratory Syncytial Virus Prophylaxis Prior Authorization Form printable pdf download

2015/2016 NEBRASKA MEDICAID RESPIRATORY SYNCYTIAL VIRUS

PROPHYLAXIS PRIOR AUTHORIZATION FORM

Client Name: ________________________________ Medicaid ID: ______________________________

Physician (print): _________________________________ Client DOB: _________________________

Gestational Age: weeks _____ days _____ Age at start of RSV season: ____________ Wt: _____ kg.



Documentation to support this clinical information MUST be included with this prior authorization



Chronological age is at the start of the RSV season



Mark which criteria applies to meet RSV needed criteria below

Gestational Age < 29 weeks and 0 days gestation and is younger than 12 months at the start of the RSV

season.

Gestational Age < 32 weeks and 0 days gestation and is ≤ 12 months of age at the start of the RSV

season with Chronic Lung Disease (CLD) and a requirement for >21% oxygen for at least the first 28

days after birth OR;

Child in second year of life who satisfies the definition of CLD above AND continues to require medical

support (chronic corticosteroid or diuretic therapy, or supplemental oxygen) during the 6-month period

before the second RSV season.

≤ 12 months of age with hemodynamically congenital heart disease (CHD) (acyanotic heart disease

requiring medication and will require cardiac surgical procedures OR with moderate to severe

pulmonary hypertension.

< 24 months of age who has undergone cardiac transplantation during the RSV season.

≤ 12 months of age with pulmonary abnormality or neuromuscular disease that impairs the ability to

clear secretions from the upper airways.

≤ 24 months of age who is profoundly immunocompromised during the RSV season.

Has the child received any doses of RSV prophylaxis this season?

Yes

No If yes, ____doses given

Physician Signature: ____________________________________________ Date: __________________

Physician Address: ____________________________________________________________________

Fax: _____________________________________ Phone: _____________________________________

Submit this form to Nebraska Division of Medicaid and Long-Term Care Program Specialist with cover sheet

indicating RSV Prophylaxis by paper Fax to (402) 471-9092 or eFax to (402) 742-1104.

DO NOT WRITE BELOW THIS LINE - FOR MEDICAID USE ONLY

Approved for RSV prophylaxis. Number of doses approved: _____________ months for dates of

_______________through ___________________.

Denied RSV prophylaxis. Rationale ________________________________________

Department Signature ________________________________________________Date ___________________

8/2015

Nebraska Medicaid Respiratory Syncytial Virus Prophylaxis Prior Authorization Form