Long rant about synagis- why didn't I know this info?

WannaBAmama

I was just BAWLING on the phone with a woman from our insurance company because LO was denied synagis for the third time. I thought he met all guidelines for the 34-36 week age group. He is under 3 months at the start of RSV season, has a sibling in preschool, and will be attending childcare.

Yet he was still denied! The reason has always been "the need is not medically indicated" I thought for SURE once I wrote my own letter using that template that was posted on here that he would get approved. I thought the insurance company must not be getting all of the information from the doctors office, they must not know he has a preschool aged sibling and will be going to childcare. So I included all of that information and when I talked to the woman today and she said he was still denied I started crying so hard and demanded to talk to a person who would tell me the exact reason he was denied again.

Here's what I didn't know......If they are born between 34-36 weeks and are under 3 months, they are only covered UNTIL they turn 3 months old. So my LO was born in August, they start giving synagis in November....he will be 3 months so he will not recieve any. If he was born in September and would be 2 months when they start synagis in November then he would only eligable for 1 shot to cover him until he was 3 months. Does that make sense? I don't know why I thought if LO was 3 months or under at the start of RSV season then he would be covered for all of the months.

The woman told me I could file one more appeal and it would go to a monthly meeting they have for the employee claims (my husband works for Cleveland Clinic- our insurance)  and they would discuss it further at the meeting. She said she can't tell me to do it or not to do it, I have the right to file the appeal but I felt like if those are the AAP guidelines I guess there's no point, if he doesnt qualify he doesn't qualify. But I hung up with her still crying and very upset. She called me back about 30 minutes later and said she has the appeal letter I sent last week (the one that was most reciently denied) and she will be taking it to the employee claims meeting at the end of the month.  I guess it doesn't hurt to try one last time....I just feel so very discouraged and stuck. Im stuck with the AAP guidelines that one give my LO the shots and im stuck going back to work in two weeks.

Im a teacher and if I would have had him last year they would have let me take a year off while still holding my position. This year they changed their policy- the will only hold our jobs for 12 weeks. I even tried asking if I got a doctors note that I need to stay home longer because he's a preemie if I can take more time off. The school board said no. I'd have to quit if I wanted any more time off. I just feel like I'm trying to protect my LO with either staying home longer or getting him synagis and no matter what I do neither option is working out for me. I feel so helpless.

WannaBAmama

CurlingRocks:

I'm so sorry!

I won't type any of the expletives that were coming out of my mouth when I read this, but please know I was a teacher before becoming a SAHM.  I have no regrets about leaving the profession after DS was born, and I was terrified of what I would bring home to him even with Synagis for the time I did return to work.  I'm sorry your employer isn't being more compassionate.  I'm sorry your son got denied his medicine.  I understand your feelings.  I wish I were more help.  HUGS!

Thanks. I would definitely be able to swing taking one school year off, but to quit and then go looking for another teaching position in Ohio next year would be pretty impossible to find.  My husband said he's all for me staying home but that would mean me having to sell my car (my hubs surprised me with a brand new car this summer), no spending money at all, and even having to pull DS #1 out of preschool that he loves because we wouldn't be able to afford the extra $200 a month for that.

IncogNeato

I'm so sorry. I loathe insurance companies. They don't even know what's good for them! Do they really think they save money by denying vulnerable babies these shots? Because even one preemie getting sick and being hospitalized probably costs them more than giving the shots to 10 kids, KWIM?

I know it isn't helpful really but my DD was a 36 weeker and started daycare at 4 months and somehow managed to never get RSV. I teach, too and she went to all all-teacher's kids daycare so it must have been dumb luck but there is some hope. 

WannaBAmama

IncogNeato:

I'm so sorry. I loathe insurance companies. They don't even know what's good for them! Do they really think they save money by denying vulnerable babies these shots? Because even one preemie getting sick and being hospitalized probably costs them more than giving the shots to 10 kids, KWIM?

I know it isn't helpful really but my DD was a 36 weeker and started daycare at 4 months and somehow managed to never get RSV. I teach, too and she went to all all-teacher's kids daycare so it must have been dumb luck but there is some hope. 

WannaBAmama

IncogNeato:

I'm so sorry. I loathe insurance companies. They don't even know what's good for them! Do they really think they save money by denying vulnerable babies these shots? Because even one preemie getting sick and being hospitalized probably costs them more than giving the shots to 10 kids, KWIM?

I know it isn't helpful really but my DD was a 36 weeker and started daycare at 4 months and somehow managed to never get RSV. I teach, too and she went to all all-teacher's kids daycare so it must have been dumb luck but there is some hope.