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The Struggle for Synagis® - Getting Your Child Approved
by Chelsey Langland
RSV, or respiratory syncytial virus, is an illness which strikes many people. Its symptoms include fever, runny nose, and a cough. For many people, they don't even realize they have it, and they recover and go on without realizing they'd been infected with anything other than a normal cold. However, for some people, the virus can be much more serious. It can result in a more severe lower respiratory infection, requiring hospitalization and on-going management of symptoms. The RSV season runs from mid- to late October through the end of April.

There is no true prevention for RSV, but a medication called Synagis® can help prevent the dangerous lower airway infections. The American Academy of Pediatrics recommends that the following groups receive Synagis® during the RSV season:

  1. Infants and children younger than 2 years of age who currently require or have required medical treatment for chronic lung disease within 6 months before the anticipated RSV season.
  2. Infants 12 months of age and younger, at start of the RSV season, born at 28 weeks of gestation or earlier
  3. Infants 6 months of age and younger, at start of the RSV season, born at 29 weeks to 32 weeks of gestation
  4. Infants 6 months of age and younger, at start of the RSV season, born between 32 weeks to 35 weeks of gestation with following risk factors: Underlying conditions that predispose to respiratory complications:
       (a) Smoke exposure
       (b) Daycare attendance
       (c) Multiple births
       (d) Number of young siblings
       (e) Anticipated cardiac surgery

Synagis® is given as an injection which lasts for approximately 28 days, so that a child would get up to 6 injections during the RSV season. Unfortunately, it is an expensive medication, which costs approximately $900 per dose.

I knew of RSV, but became much more aware of it after I delivered a premature baby in late April of this year. I asked our nurses about Synagis®, and was told that since I delivered before 32 weeks, my insurance company would certainly agree to pay for her Synagis®.

Fast forward to mid-October, when my pediatrician attempted to get pre-approval for Synagis® from my insurance company. We were denied, on grounds that the claim was "not medically necessary." That was unacceptable to me, and I worked hard at getting the decision reversed. Fortunately, we were successful. I later learned that many insurance companies are hesitant to pay for Synagis®, and that denials are very common. In hopes of keeping children healthy, I'd like to pass along what worked for me.

Appeal your insurance company's decision. Every health plan allows you to appeal an adverse decision regarding coverage. You can provide the company with additional information, such as the fact that your child is in daycare or has older siblings. However, in my experience, you need to have your health care provider working for you. Have the provider send copies of your child's chart, along with his or her opinion on the benefits of Synagis®. In addition, you may request a "peer to peer" review. That allows your health care provider to speak with the pediatric medical director of your health insurer.

Utilize your state's insurance commissioner. All states have Commissioners of Insurance, who regulate sales and policy management. All of the departments have some variety of consumer assistance division, which exists to help policyholders who are having a coverage dispute. The commissioner's office will send a formal complaint notice to the company, and can do some of the mediation for you, without you having to speak with the company. In addition, some insurance companies will quickly resolve disputes, to avoid having lots of complaints on file. You can find contact information for your state's department at The National Association of Insurance Commissioner's Website.

If these routes fail and you cannot obtain insurance coverage, try working with a program like MedAssist which provides assistance and reimbursement for those without insurance coverage. Income guidelines do apply, and your health care provider will need to complete the paperwork.

It is frustrating when insurance woes keep your child from getting the help he or she needs. Hopefully, these tips can help you keep your child safe this cold and flu season.

Chelsey Langland became a preemie mom when her daughter was born 8 weeks early. Before that, she dealt with extensive infertility issues. She and her husband are enjoying parenting more than they ever thought possible. In her non-parenting time, Chelsey works as an attorney in public service.

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