DS Just got denied Synagis — The Bump

DS Just got denied Synagis

Just got a call from the pedi and our insurance company is stating he does not meet qualifications for Synagis. He was born at 32w4d and apparently the cut off is at 32 weeks. Pedi's office also said that he had to be less than 3 months old at the "commercial start" of RSV season which is on 11/15 (he will be four months by then). The nurses at the NICU said that I needed to "push" for Synagis since he was so close to the cut off. Anybody run into this same problem? Is there anything I can do about it?
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Re: DS Just got denied Synagis

  • I pushed and got my girls approved last year. They were born at 34w5d and were May babies so 5-6 months old at the start of RSV season. I talked to my insurance company and found out exactly what information they needed and then had my pedi's office fax the appeal. I included details that they were multiples, one was IUGR, spent time in the NICU etc. If your LO required any breathing help I think that would be a good thing to note too.

    We ended up getting approved, but not using them because even with copays we would have had to pay about $3500 out of pocket. Thankfully they still haven't been sick, but I hate that preemie moms have to fight so hard to protect their babies from RSV. It is ridiculous considering the cost of RSV to our insurance companies.

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  • I'm sorry you got denied. I would also call up your insurance and talk to them to see if they can work something out. My DS got it last year, and I'm already pushing for him to get it again this year. This year is looking iffy since he is older now, but I'm still going to try.
  • I don't know if this will help but here if you cannot afford the Synagis, even if you can't afford the copay there is a charity that will buy it for your LO. Maybe there is something like that? Ask the social worker that is assigned to the NICU.

    *I just thought to add that maybe my advice is completely unhelpful because I am outside the US* 



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  • I have twin daughters, and I am going thru this too.  1 of my daughters was denied....she was born at 32 weeks....and was IUGR.  She really needs the vaccine, and I am at a loss at what to do.
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  • My son just got approved for it (he was born at 31w1d), and I'm waiting on Home Health to call and set up the first meeting.  I'm a new mom...can anyone tell me exactly what to expect??  I'm not even sure I have a full understanding of RSV...
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