Statement Of Medical Necessity Form - Synagis
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Tel: (800) 906-7798
SYNAGIS (palivizumab)
Fax: 877-381-3806
STATEMENT OF MEDICAL NECESSITY
Please complete this form (PRINT) in its entirety and fax it to the number below.
Be sure to enclose any necessary documentation, labs, insurance cards, etc.
DEMOGRAPHICS
M
F
Last Name
First Name
Middle Initial
Address
Apt#
City
State
ZIP
Home Telephone
Work Telephone
Cell Phone
E-mail
Date of Birth
Social Security Number
Allergies
INSURANCE INFORMATION
Please include copies of the patient’s insurance/drug benefit cards (front and back) to expedite benefit clearance.
Primary Insurance Name
Policy Number
Group Number
Policy Holder
Employer
Insurance Telephone Number
PRESCRIBER INFORMATION
Prescriber’s Name
Clinic Name
Specialty
Address
Suite#
City
State
ZIP
Contact Name
Telephone
Ext./Direct Telephone
Fax
Email Address
License Number
DEA #
NPI #
CLINICAL INFORMATION
TO ENSURE PROMPT PROCESSING PLEASE COMPLETE ALL OF THE QUESTIONS
.
Patient’s Gestational Age: ______ weeks ______ days Birth Weight: ______ g / kg / lbs Current Weight: ______ g / kg / lbs Date recorded: _________
__________
Please Document All Diagnoses and to the Highest Degree of
Medical Criteria
(Please attach clinical documentation for all diagnoses below)
ICD-9/ICD-10 Detail
ICD-9
ICD-10
Yes
1. Diagnosis of Chronic Lung Disease (CLD) (ICD-09:770.7/ ICD-10:P27.8)
No
≤ 24 Weeks.............765.21—765.22.....P07.21-P07.22
Oxygen
Concentration: ________
Dates: ______________
25 Weeks....................765.23.....................P07.24
Supporting clinical documents are attached for Oxygen use
26 Weeks...................765.23....................P07.25
Bronchodilator
Corticosteroids
Diuretics
27 Weeks....................765.24..................... P07.26
____/____/____
____/____/____
____/____/____
28 Weeks....................765.24....................P07.27
2. Diagnosis of Hemodynamically Significant Congenital Heart Disease?
ICD-9/ICD-10 ______
No
29 Weeks....................765.25....................P07.32
Patient has the following Conditions
:
Yes
30 Weeks....................765.25....................P07.33
Diagnosis of Moderate-Severe Pulmonary Hypertension
31 Weeks....................765.26....................P07.34
Cyanotic Heart Disease
Acyanotic Heart Disease
32 Weeks....................765.26....................P07.35
____/____/____
Medications for CHF: (list) ____________________________ Last Date Received
33 Weeks....................765.27....................P07.36
Recent surgical procedure requiring cardiopulmonary bypass
34 Weeks....................765.27....................P07.37
No
Yes
If yes, an additional post-operative dose of palivizumab may be medically necessary
35 Weeks....................765.28....................P07.38
36 Weeks....................765.28....................P07.39
ICD-9/ICD-10: __________
3. Diagnosis of Cystic Fibrosis with one of the following risk factors?
No
Clinical Evidence of CLD
Yes
37 Weeks....................765.29......................N/A
Nutritional Compromise
Other Respiratory Conditions of Fetus and Newborn
ICD-9/ICD-10: __________
Manifestations of severe lung disease (previous hospitalization for pulmonary exacerbation in the first
Secondary Diagnosis (If Applicable): __________
year of life or abnormalities on chest radiography or chest computed tomography that persist when
Breakthrough RSV hospitalization
stable)
th
Weight for length less than 10
percentile.
Additional Risk Factors:
Child Care Attendance by the infant home or facility
Sibling (s) younger 5 years of age living in the same household
4. Diagnosis of profoundly immunocompromised? Reason: ________________________________________
No
Yes
5. Diagnosis of Congenital Abnormalities of the airway and 12 months of age or less?
NICU HISTORY
No
Yes
NICU Name
______________________
ICD-9/ICD-10 __________
Please Attach the NICU Discharge Summary
6. Neuromuscular condition that compromises handling of respiratory secretions and 12 months of age or
No
___/___/___
Yes ICD-9/ICD-10 __________
Was there a NICU Dose Administered?
No
Yes
Dates:
less?
Expected Date of First / Next Injection
___/___/___
Previous Injections?
No
Yes
Dates:
___/___/___
Agency Nurse to Visit Home for Injection?
No
Yes
Rx Synagis (palivizumab) 50mg and / or 100mg Vials
Parent / Caregivers have been Contacted and We Have Been Granted
Sig: Inject 15mg/kg IM One Time Per Month
Permission to Contact
Dispense Quantity: QS
Refills Through ___/___/___
Rx
Other:
Physician Signature
Date
Deliver Medication to:
Patient’s Home
Physician’s Office
Other
Thank you for using Acro Pharmaceutical Services!
Fax completed form to 877-381-3806 /
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