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RSV - 2nd year Synagis denial

naterbugsmom
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Hi, my son Nathaniel "Naterbug" was born at 35 weeks due to my having severe pre-eclampsia which caused IUGR. He only weighed 3 lbs 15 oz and was 16 in. long.
Last year we qualified for Synagis becuase he was 3 months old at the start of RSV season and met 4 of the qualifying risk factors. This year we still have all the same risk factors with another child starting school so at his daycare there will be 2 school aged children coming in in the afternoons. I was told by my sons nurse that he would not qualify this year becuase he does not have a chronic lung or heart condition. Is anyone else having this problem....what can I do?

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Dehydration Eclampsia

14 replies

katek

I suspect that it differs from insurance company to insurance company. I believe that in our case (25-weeker with CLD, just turned 1 yr adjusted), we'd need a letter from his pulmonologist, apply through the pulmonologist, and then write an appeal upon denial. Incidentally, other than his CLD, we don't have additional risk factors and were told that w/o the risk factors, it would almost certainly be denied again (this was last year when I asked).

We haven't talked to his pulmonologist to get the ball rolling yet.

Does anyone know if Synagis is as effective the second year as it is the first?

momof4frompa

usually a 35 weeker if no previous issues occured during the RSV season will not quailfy for a 2nd year synagis shot..
Its depending on the child's gestational age, and requirements. Such as CLD.
My 2 30+ weekers didn't qualify for the 2nd yr synagis.
How ever my 24 weeker, with CLD and other issues, he will most likely be covered. We will know come October when they put in for the 1st request and most likely have to go thru the appeal process.
2nd years are very hard to get covered.
Unless oxygen dependent or apnea still occurs, CLD etc..
I think Synagis can be very affective the 2nd year if they are prone to being sick.
but at 1500 dollars a shot most families cant afford to pay that every month for the winter season.

woody126

I have a 27 weeker who was born in December of 2006 and came home in February. He got Synagis for the remainder of RSV season (March & April) and then qualified for it for last year because he was a micropreemie. He will be 2 in December and will not qualify for Synagis this year. I haven't heard of a 35 weeker getting synagis at all unless they have lung issues or were on a ventilator for a long period of time, but i think it really depends on your doctor and insurance. I would talk about it with your pediatrician and voice your concerns and see if she can help ease your mind about not having the shot this year OR help you qualify.

funkyme

hi, just to clarify - Synagis is not a vaccination. It actually inject antigens into the body directly - so no question of whether it will be effective or not. Antigens boost the fighting power of the child's body (it is what the body would have produced after a regular vaccination to fight of the vaccine). Anytime the child gets a Synagis shot, the body is stronger.

Yolonda

My 23 weeker who is now 3 years old still qualifies for synagis again this season. Last December (she was 2 1/2) she caught RSV (first season without synagis) and ended up intubated and on the vent for 7 days. The virus just went on the attack of already fragile lungs. We spent both Christmas and New Years in the hospital last year with a 13 day hospital stay in all.

She has no other risk factors other than CLD (only child, does not attend day care or any type of school yet). In our case, we did not have to fight. Like her pulm said a covering the shots for the season is like cab fare in comparrison to what they paid out last year for her hospital stay.

And funkyme you are aboslutely right, that is why you have to get the shot every 4 weeks instead of just once like other vaccinations.

emsmom

Most insurance companies go by the CDC guidelines for who qualifies for synagis. You should be able to find the guidelines on the cdc website cdc.gov. Also the cigna website has a coverage position paper that you can get by going to cigna.com and doing a search for synagis. The coverage positions aren't the same for all insurance companies but cigna goes by the CDC guidelines so it may give you an idea if your child will qualify.
Hope this helps
Mary

brneyedgrl827

i don't know how many insurance companies go by guidelines similar to these, but i found this interesting PDF on guidelines for synagis authorization.

https://www.mhswi.com/portal/wcm/resources/file/eb6d4e0042c1fbb/2007-2008_S ynagis_Guidelines.pdf

as far as i know, my daughter does not qualify for synagis this year because she is already over a year old, does not have any chronic lung/heart problems, and has no risk factors (i'm a SAHM, she's an only child, neither my husband nor i smoke). according to our pulmonologist, she might have qualified for a second year of shots had she been a fall or winter baby (born at 28 weeks and 0 days...which is what she was) because then she would still be less than a year old at the start of RSV season. last year, she received seven doses (october-april).

i'm a little nervous about what this season will hold for us without the extra immunity boost...we are going back into "hibernation" (perhaps slightly more relaxed this year) and sticking to our compulsive hand-washing in hopes of keeping her well for at least one more winter; by then, her lungs and immune system should be relatively "caught up".

i'm curious as to how everyone handled their second RSV season and beyond...did you stay indoors? did you go about the same routines regardless? when did you feel or when do you think you will feel like you had/have the green light to just be normal?

wyattsmommy

My son born at 30 weeks in end of March got 1 synagis shot before he went home from the hospital. Then he started up on them again in the fall. We switched insurance from Blue Shield HMO to Blue Cross PPO and the new insurance denied it in the middle of his first synagis season (go figure pay more and get denied). Needless to say I prayed about it and didn't fight them (by this time I had fought so much- reason for switching ins). My son was fine he catched his first little cold at 11 months old. We stayed inside whenever the weather was questionable and missed family functions if someone had the sniffles. I also was huge on anti-bacterials. I also put him on that formula by good start Natural Cultures to help their immune system. I still have to put some formula in his whole milk (i don't like pedisure-full of sugar) so they have a 2nd step Ill fortify his milk with. Being his second year I will probably do close to the same thing maybe not as extreme.

melanie9392

My 35 weeker will receive it all this year but probably not next year bc the qualifications are changing and she has no chronic heart or lung problems. It seems that by age two your son would be better able to fight the virus. How did he handle the monthly shots when he was little?

Rika

my dd is 11 month adj 15month actual preemie. she was born at 24 wks and 4 days and does have the cld and she is on two type of inhallants and they denied her for this year. i am hoping the ped will be able to get them to change their mind but im a bit worried. i was told the requirements how who is gonna get it and whos not have gotten much stricter this year and many are getting denied. good luck!

naterbugsmom

Wow - this is an old post I started last year. He made it through his second year without it just fine. I was just freaking out because I had the comfort of knowing he got the monthly injections his first winter. It was scary but we just kept him in.

He did well with the monthly shots, he'd fuss when they gave it to him but other than that - you'd never know he was getting them.

We are starting in to our third winter - and we have just gotten over a virus, a secondary bacterial infection, and his blood work tested positive for mono. So we have had a rough couple of weeks.

Praying for a healthy winter for all of you.

browneyed_girl1975

Our insurance company just sent us a letter saying that synagis for our girls would be "medically appropriate" but not "medically necessary" so it "may not be covered." So upset because we do not have money to pay for this. With H1N1 and everything else I am driving myself crazy with worry.

naterbugsmom

Will you doctor call in and tell them it is medically necessary and appeal it if they deny. Also you should contact Patient Access Network - wonderful organization that helps you pay for Synagis.

lchang4

BTW, Synagis actually contains antibodies not antigens.

About insurances....

My kids have Empire Blue Cross PPO as primary thru my husband's work and Blue Shield of CA PPO as secondary thru mine. We are lucky that Blue Cross has been just great so far. We were in shock when the twins were born at 25 weeks gestation and didn't add them to Blue Cross until 2 months later. Yet they still covered everything since their birth.

Both insurances had a case manager to monitor the girls' progress during the NICU stay but the Blue Shield one was a bxxxx. She really scrutinized everything the doctors ordered. If you are looking for insurance, stay away from Blue Shield.

With Blue Cross, after coming home, we still have a case manager to help with our insurance needs. I give all our doctors and therapists her phone # and they can call her for authorization directly. I also try to be on friendly terms with her and update her with the girls' progress from time to time. It really helps our case to have them hear our voice. My girls just got approved for a second season of Synagis. They don't have any lung problems. But I told her they are just one infection away from ending up in the hospital due to Twin A's kidney disease and Twin B's not feeding well (dehydration risk). I know for all insurances, if they deny something, you can always appeal. Ask them about the appeal process.

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