Getting ins. approval for Synagis for 2nd season

[GOPLawyer]

Has anyone had any luck getting approval for the synagis shot for the 2nd season?

I just talked to DD's ped. and was told that ins. companies are being quite stingy w/ the shot this year. She actually laughed (in a sympathetic way...she's very sweet) when she noticed I had UHC.

DD was born at 30 weeks, was on a vent. for a few days and caught meningitis while in the hospital. She'll be a year old on Nov. 17th. The NICU docs said a 2nd round would be a piece of cake to get approval for...looks like that's not the case.

Any advice/stories/tactics?

TIA!

[princess_tre]

I'm in the same boat. Hope someone has some advice/encouragement.

[yogafeet]

IME you should be able to get a second round of Synagis. The only thing I see that might mess it up is her birthdate and when RSV season starts where you live. Generally if your baby is under one at the beginning of the season she will qualify, or at least that is what I remember. However, your doctor should be able to use the fact that she not only was a 30 weeker but also on a vent and had menengitis to convince the insurance to cover it. All insurances are different... but I do remember that some nurses were surprised that my twins were getting it from Aetna b/c they are known to be stingy. They are January babies but were also 30 weekers but qualified for 5 rounds of Synagis last year, which was their second RSV season.

I know this can be stressful- hang in there! Even if they say no, she is one and that is fabulous! She is older a more capable of dealing w/ RSV. (Totally saying that to make you feel good and not to poo-poo, I was jonesing for that Synagis a year ago!)
Good luck!

[sunflowers]

Originally Posted by yogafeet

IME you should be able to get a second round of Synagis. The only thing I see that might mess it up is her birthdate and when RSV season starts where you live. Generally if your baby is under one at the beginning of the season she will qualify, or at least that is what I remember. However, your doctor should be able to use the fact that she not only was a 30 weeker but also on a vent and had menengitis to convince the insurance to cover it. All insurances are different... but I do remember that some nurses were surprised that my twins were getting it from Aetna b/c they are known to be stingy. They are January babies but were also 30 weekers but qualified for 5 rounds of Synagis last year, which was their second RSV season.

I know this can be stressful- hang in there! Even if they say no, she is one and that is fabulous! She is older a more capable of dealing w/ RSV. (Totally saying that to make you feel good and not to poo-poo, I was jonesing for that Synagis a year ago!)
Good luck!

to the part I bolded. My dd was a 27 weeker, born in October (a real squeeze between her Bday and start of the season). She qualified for a full second season from Aetna. She had no significant breathing issues, either.

I do seem to recall they had to appeal once but it seemed that they may have to appeal for a second season for all their babies. The peds office took care of all of the paperwork and appeal All I had to do was arrange that the meds got delivered to the peds office and pay for the pharmacy copay.

I wish you luck and a healthy winter whatever happens!

[GOPLawyer]

Thanks so much for your replies!

I had a huge list of reasons to get the shot written down...I was ready for a fight. I simply asked what the approval process was, I was put on hold for about 5 minutes or so and then told it was approved. The ped was as socked as I was. DH thinks the NICU doctor put in an order for 2 seasons (do they even do that?).

I am over the moon happy!!

[sbrinton]

Zeph was born on November 18 at 31 weeks. He was on CPAP and then has been okay, but with big brothers in the house he is exposed to everything. Should we try for a second round of synagis?

[princess_tre]

I just got off the phone with the ped. They said that the APA has redone their recommendations for the shot and not many will be approved at all for it. She said, no one (I'm in IL) will get it if it's their second season, and only those babies born this season 30 weeks or under will get a total of 3 shots max.

I inquired if it had anything to do with insurance, because I have very good bcbs, but she said no. I will be inquiring again, but her reason was the APA saw no direct benefit. bummed.

[GOPLawyer]

Originally Posted by sbrinton

Zeph was born on November 18 at 31 weeks. He was on CPAP and then has been okay, but with big brothers in the house he is exposed to everything. Should we try for a second round of synagis?

I would. It never hurts to try.

I just got off the phone with the ped. They said that the APA has redone their recommendations for the shot and not many will be approved at all for it. She said, no one (I'm in IL) will get it if it's their second season, and only those babies born this season 30 weeks or under will get a total of 3 shots max.

I inquired if it had anything to do with insurance, because I have very good bcbs, but she said no. I will be inquiring again, but her reason was the APA saw no direct benefit. bummed.

Here's a release from Preemies Today WRT the new guidelines.

You might also find this and this page helpful.

I wouldn't take the peds word for it. My ped pretty much told me there wasn't a chance and she was wrong. Go to your insurance company.

[yogafeet]

Originally Posted by sbrinton

Zeph was born on November 18 at 31 weeks. He was on CPAP and then has been okay, but with big brothers in the house he is exposed to everything. Should we try for a second round of synagis?

Absolutely. The older brothers will be a pull for a yes from the insurance co.

Originally Posted by GOPLawyer

Thanks so much for your replies!

I had a huge list of reasons to get the shot written down...I was ready for a fight. I simply asked what the approval process was, I was put on hold for about 5 minutes or so and then told it was approved. The ped was as socked as I was. DH thinks the NICU doctor put in an order for 2 seasons (do they even do that?).

I am over the moon happy!!

YAY! I am so happy for you. This takes a load off.

[Barefoot Farmer]

GOPLawyer, Congrats. That is such a huge relief.

DD was a 30 wker and we were told then (5 yrs ago) that she wouldn't be approved for a second season b/c her health was so good (1st year/season she had not one cold). I didn't even think to contest it. Sure enough, 2nd season she got RSV -- she handled it with a brief hospitalization, no lasting effects, but in hindsight I wish I had known or even thought to fight for a 2nd season.

Best of luck to you all.

[sparklett]

FWIW, we were approved for a second year (this was last year) because our doctor had a freakishly AWESOME billing staff who were willing to do whatever it took to get us approved. We sent them chocolate on three different occasions (after the got us really fast referrals and approvals). I know many people will never meet their billing staff, but because we were with a very small practice, they had the time to dedicate to special patients. I'm 100% positive we wouldn't have had the same outcome if we were with a larger practice.

[OGirlieMama]

I'm so glad you were approved! My girls were approved for a 2nd season, because our insurance company (Aetna) had their own criteria, which were actually *more* inclusive than the AAP guidelines at the time. The ped didn't think Lilly would be approved for the second season at all, and thought maybe Kate would be, but in the end they both were. It always helps to check your insurance company's website and see if they have their guidelines published there.

[beckylynn]

I have twin girls, born at 29 weeks in March. They were in the NICU for 8 and 10 weeks and caught RSV at the end of July (NOT in RSV season). It was awful and they were hospitalized for 5 and 10 days respectively. That being said, we also have UHC and they did approve us for the shots, but only starting in November (though they consider October the start of RSV season).