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Preemies
Fed up with Insurance
This is going to be a major vent. I am sick over this; so increibly frustrated and feel so helpless.
LO has received 5 synagis injections so far this season, but the season is peaking later than anticipated and he needs at least one more shot. Insurance is denying the 6th shot saying he only gets 5. Our clinic has already called to push the issue (I forget the technical term for that, something like peer-to-peer consult) and they are still denying it.
I just don't see how a doctor can say that something is medically necessary and the insurance company can say no. I called for another opinion to our NICU who said that yes, their patients are still getting synagis right now due to high numbers of RSV and that our LO should have another injection.
I have a call in requesting a price estimate because we've yet to see any numbers on how much this would cost us out of pocket. I can't justify putting LO's health at unnecessary risk after all we've been through, so I guess we are going to have to cover this out of pocket.
I'm looking into appealing, but that won't be finalized prior to needing the injection (March 22nd), so the clinic said we'll have to pay in the mean time. Insurance company also makes the appeal process so difficult to even understand (by educated people) that it just infuriorates me. I have done everything they've asked of me and yet we are still fighting this battle. Just getting the initial 5 injections covered was a major ordeal. How can they penalize us & my LO for RSV peaking later than anticipated??? That is just cruel.
Thanks for understanding. Any appeals advice? At this point I don't even know what to write, what to include, etc. I'm guessing I need data showing local RSV numbers but don't know where to get that either. I am just so, so sick of this all.
This discussion has been closed.
Re: Fed up with Insurance
Exactly. Well stated.
Do you stay home with DS or does he go to daycare?
If he is in daycare I would say definitely appeal it, but by the time it is settled he may very well not need it anymore.
If you are home, I would personally just skip it and stay in until April 1st. My Jacob was 24w5d just like your Jacob
and unfortunately my company was sold to another company 10 days before I quit. It took 4 months for them to iron out who would be providing my COBRA coverage, the old company or the new company. Needless to say, they never got it settled and DS didn't get ONE shot at all the entire first Winter of his life.
We ended up just being very cautious about hand sanitizer, who came over and where we went. He also didn't qualify for the shots after his first Winter so I am actually surprised you were able to get them for your DS this year. DS had CLD/BPD and didn't even catch a plain, old cold never mind RSV so I think if you're careful (since it is only one shot he is missing) he should be fine.
Jacob 3.23.08 * Grace 7.22.09 * Eli 7.26.11 * Annabelle 1.18.14
What a mess with all of your COBRA coverage. Ick.
DS only had 2 last year (his first partial winter) due to the timing of his birth & when he was released from the hospital. He qualified this winter because he was still on oxygen pretty close to the start of RSV season which apparently means that his lungs were still compromised enough to warrant a second season.
I stay home and we are and have always been super careful. He doesn't go out in public, we only have his grandparents at our house and no one else, we wash and sanitize a ton, and he's yet to get sick. RSV is peaking late in our area and they are still seeing lots of cases, so I doubt it will be done by April 1st. Still I realize the risk should be fairly low given his age and being at the late end of the season, but with all he and we have been through, I still can't see taking any unnecessary risks. I would have a hard time forgiving myself if we don't get the shot and then he gets RSV and ends up in the hospital, maybe even back on the vent which is what his pedi has been telling us is a real risk.
So, we are going to get the synagis on March 22nd and in the meantime start the appeal process. We'll likely be paying out of pocket until the appeal is settled at least (hopefully in our favor). What really irked me is that the insurance rep who called to tell me it was denied (again) said that as a parent, she'd have him get the shot and in the meantime work on the appeal. So basically she's telling me that he needs the shot, and yet they are denying it because he doesn't need it. ARGHHHHH.
Is your insurance company UHC? Because ours is and we went through the same thing and are STILL going through it. Just let me know if it is UHC b/c I'm making a voodoo doll as we speak and I would have no problem making a second one on your behalf.
Seriously, though, it seems they are more responsive to medical professionals than us "little people." Whoever you can get to lobby on your behalf-- the pedi, the NICU, her attending physician in the NICU, etc.
Good luck and I'm sorry you have to deal with these heartless thieves.