Health Authority – Abu Dhabi

HAAD Standard for Prophylaxis to reduce the risk of respiratory syncytial

Document Title:
virus (RSV) in high risk infants
Document Ref. Number: HAAD/PRSV/SD/0.9 Version 0.9
Approval Date: 15 September 2012 Effective Date: September2012
Last Reviewed: N/A Next Review: December 2013
Revision History N/A
Document Owner: Policy and Research, Policies and Standards
Applies to: All licensed healthcare facilities
Classification:  Public

1. Purpose:
1.1. This standard establishes the clinical and health insurance reimbursement eligibility
criteria for the prophylaxis treatment of respiratory syncytial virus (RSV) infection.
2. Scope
2.1. This standard applies to:
2.1.1. All healthcare facilities and professionals licensed by HAAD;
2.1.2. Healthcare insurers and third party administrators (TPAs); and
2.1.3. Medical billing service providers.

3. Duties for healthcare facilities, professionals, insurers and TPAs and medical billing providers:
3.1. All licensed healthcare facilities and professionals must:
3.1.1. Deliver clinical services and patient care in accordance with the laws and
regulations of the Emirate of Abu Dhabi and consistent with HAAD Policies and
Standards;
3.1.2. Provide patient treatment and care services for the prophylaxis treatment of
respiratory syncytial virus infection in accordance with the requirements of this
Standard, including patient eligibility criteria, healthcare professionals prescribing
requirements, and the health insurance authorization rules and regulations;
3.1.3. Ensure that the treating and responsible physician obtains the patients’ parents or
guardian informed consent for the treatment in accordance with the HAAD
Policy on Consent, and that consent or refusal of treatment is documented in the
patients file;
3.1.4. Ensure that patients who meet the eligibility criteria for RSV prophylaxis as set out
in Standard 2 receive the treatment course in accordance with that
recommended in this Standard, except where it is the judgement of the
responsible treating physician to change the course or dose of treatment for the
patient’s best treatment outcomes. Where this is the case, it is the responsibility
of the treating physician to ensure the decision is based on evidence and that

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 such evidence is documented on patient files, and that the patient’s parents or
guardian have been informed;
3.1.5. Comply with the provisions of the HAAD Standard Provider Contract, the HAAD
Coding Manual and the HAAD Mandatory Tariff and associated Claims and
Adjudication Rules, and the eClaims requirements;
3.2. HAAD licensed insurers, and associate TPAs, operating in Abu Dhabi must comply with
the criteria for authorising health insurance reimbursement for RSV treatment as
specified in this HAAD Standard
4. Enforcement and Sanctions
4.1. Healthcare Provider, Insurers, TPAs and Medical Billing Office must comply with the
terms and requirements of this Standard. HAAD may impose sanctions in relation to
any breach of requirements under this standard in accordance with the [HAAD Policy
on Inspections, Complaints, Appeals and Sanctions].
5. Standard 1 - Definitions
5.1. Respiratory Syncytial Virus (RSV): is a common cause of respiratory infection in infants
and children that can result in bronchiolitis or pneumonia.
5.2. Chronic lung disease (CLD): is defined as bronchopulmonary dysplasia (BPD) or chronic
respiratory distress in a preterm infant who has had an oxygen requirement lasting
more than 28 days and who exhibits parenchymal changes on x-ray necessitating
medical therapy as outlined in this Standard.
5.3. RSV season as defined by the CDC as “the first of 2 consecutive weeks during which
the mean percentage of specimens testing positive for RSV antigen is 10%.” RSV
season offset is defined as the last of 2 consecutive weeks during which the
percentage of positive specimens is less than or equal to 10%. or between (usually
between October 1 and March 31).

6. Standard 2 - Eligibility Criteria for RSV prophylaxis

6.1. Children at or under the age of 24 months at the start of the RSV season with chronic
lung disease (CLD), who require medical therapy (i.e. supplemental oxygen,
bronchodilator, diuretic or corticosteroid therapy) or have received medical therapy
within the 6 months preceding the RSV season;
6.2. Children at, or under the age of 24 months at the start of the RSV with congenital
heart disease including; congestive heart failure, pulmonary hypertension, or
hemodynamically significant cyanotic and a cyanotic congenital heart disease;
6.3. Infants/children are NOT considered at increased risk from RSV and are not eligible
for RSV Prophylaxis if they have any of the following conditions and do not satisfy any
other eligibility criteria:
6.3.1. Hemodynamically insignificant heart disease i.e. Secundum atrial septal defects
(ASD), small ventricular septal defects (VSD), Pulmonic stenosis, uncomplicated
aortic stenosis, Mild coarctation of the aorta and Patent ductus arteriosus (PDA);
6.3.2. Infants with corrected surgical lesions unless they continue to require medication
for Congestive heart failure (CHF);
6.3.3. Infants with mild cardiomyopathy who are not receiving medical therapy;

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6.4 Premature infants born before 32 weeks gestation (31 weeks and 6 days or less) who do not
meet the criteria in 6.1 and 6.2, but who meet any of the following criteria:
6.4.1 Infants born at less than 28 weeks of gestation and are less than 12 months old at
the start of the RSV season; or
6.4.2 Infants born between 29-32 weeks of gestation (31 weeks and 6 days or less) and
are less than 6 months old at the start of the RSV season; or
6.4.3 Infants born between 32-35 weeks of gestation (35 weeks and 6 days or less), are
less than 3 months old at the start of the RSV season and with at least one of factor i.e.
attending daycare, or have siblings less than 5 years old at home. In such cases, infants
must be offered a prophylaxis dose until they reach 3 months chronological age (a
maximum of 3 doses)
.6.4.4 Infants less than 24 months of age at the start of the RSV season with congenital
abnormalities of the airway or neuromuscular diseases that compromise handling of
respiratory secretions;
6.5 Immunocompromised infants with severe immunodeficiency will be considered in
accordance with medical necessity on a case by case basis by the responsible treating physician;
which must be supported by evidence based medical practice(refer Standard 5 of this Standard),
who will decide on the eligibility;
6.6 Infants with cystic fibrosis and who are less than 24 months of age at the start of the RSV
season will be considered in accordance with medical necessity on a case by case basis by the
responsible treating physician which must be supported by evidence based medical practice
(refer Standard 5 of this Standard), who will decide on the eligibility.

7. Standard 3 – Service Specifications

7.1 Whenever practical, healthcare facility specific arrangements should be made to allow
vaccine vial sharing in order to maximize the benefit of the prophylaxis treatment;
7.2 Prophylaxis treatment must only be recommended by the following healthcare specialties,
with the prescribing professional licensed at Consultant or Specialist level for
7.2.1 Pediatrician;
7.2.2 Neonatologist;
7.2.3 Cardiologist;
7.2.4 Pulmonologist.
7.3 Each healthcare facility must have in place optimized processes and operating procedures to
implement these standards in the most cost-effective manner.

8. Standard 4. Payment Mechanism

8.1 For high risk infants, meeting the criteria defined in standard 2 “Eligibility criteria for RSV
prophylaxis”,
8.1.1 Cost of administration of RSV prophylaxis, including: consultation, vaccine cost and
other supplies, shall be covered under insurance plans (Basic, Enhanced and Thiqa) for the
eligible members as any other medical condition;

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 8.1.2 Coverage under health insurance ends at age of 24 months (last day of child’s
birthday month).
8.1.3 Coverage under health insurance shall be limited to five doses. Doses administered
during hospitalization are included as part of these five covered doses;
8.1.4 Member liability, as defined in the plan document, applies.
8.2 For patients not meeting the criteria defined in standard 2,
8.2.1 Cost of administration of RSV prophylaxis will be considered Preventive services /
vaccinations / immunizations; and
8.2.2 Must be subject to insurance plan exclusions.
8.3 Coding of services prescribed by this standard, and any related services, shall follow the
Codes Classification defined in the Coding Manual for telemedicine published by the Clinical
Coding Steering Committee, and in compliance with e-claim requirements.
8.4 Reimbursement rate for services prescribed by this standard shall be in accordance with
Standard Provider Contract, HAAD Mandatory Tariff and associated Claims and Adjudication Rules,
all documents are available at the HAAD website in Data Dictionary.

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