Doctor won't give twins RSV shots....

Discussion in 'The First Year' started by desolation_anonymous, Feb 4, 2009.

  1. desolation_anonymous

    desolation_anonymous Well-Known Member

    Nikola had gotten really sick, rushed to the ER twice this weekend and is STILL on a albuterol nebulizer at home. X-rays showed might be some viral pneumonia going on. Diagnosed with Bronchilolitis and on antibiotics, etc.

    It was NOT RSV or the flu. I have asthma, so he might develop it later. His ID twin didn't get this sick. They are now 13 weeks.

    What terrifies me, is if he got this sick from a regular COLD what happens if he gets RSV? I have to have them in daycare...
    she has a no sick policy but can't help if people show up with sick kids, or kids start getting sick there... and right now she herself and her teenage daughters have colds...

    they were preemies born at 35 weeks and 5 days. Alexander had breathing tubes. They spent 11 days in the NICU.

    They were multiples (which also puts them at risk)

    And they attend daycare (which also puts them at risk)

    The doctor told me that Kaiser will not give shots of Synagis unless the babies were born under 32 weeks.

    Um, aren't there additional risks I've heard so much about?

    GRRRRR...
     
  2. Fossie

    Fossie Well-Known Member

    Mine were initally denied and were then approved after getting RSV! Some of the factors that they considered for us were:
    1) When they were born, for us it was less than 34 weeks (we were denied because ours were born at 34 weeks, 5 days)
    2) Birth weights - under 5 pounds is what we were told which is why my boy was approved and then not my girl until after she got so sick.
    3) Older children in the home or daycare (ours are in daycare)
    4) Wood burning fireplace or living with a smoker (this one did not apply)
    5) History of asthma or severe allergies (my dh had asthma as an infant)

    Like I said we did not get approved at first but once they were sick (bronchiolits, not officially RSV) they started giving them the shots - the nurse had to resubmit an appeal and that was approved.They are both on nebulizers now and get their RSV shots monthly.
     
  3. AimeeThomp

    AimeeThomp Well-Known Member TS Moderator

    That stinks that they aren't covered. I hope they are feeling better soon. :hug:
     
  4. Leighann

    Leighann Well-Known Member

    Mine weren't covered either even though they were born at 34 weeks, M had some breathing issues in the NICU, both were under 2000g for their birth weights and our sitter has older children. We just followed strict precautions- lots of hand washing, and thankfully they were fine last year. :hug:
     
  5. ladybutterflyrose

    ladybutterflyrose Well-Known Member

    I don't blame you for feeling aggravated. :hug:
     
  6. desolation_anonymous

    desolation_anonymous Well-Known Member

    QUOTE(Fossie @ Feb 4 2009, 04:05 PM) [snapback]1176316[/snapback]
    Mine were initally denied and were then approved after getting RSV! Some of the factors that they considered for us were:
    1) When they were born, for us it was less than 34 weeks (we were denied because ours were born at 34 weeks, 5 days)
    2) Birth weights - under 5 pounds is what we were told which is why my boy was approved and then not my girl until after she got so sick.
    3) Older children in the home or daycare (ours are in daycare)
    4) Wood burning fireplace or living with a smoker (this one did not apply)
    5) History of asthma or severe allergies (my dh had asthma as an infant)

    Like I said we did not get approved at first but once they were sick (bronchiolits, not officially RSV) they started giving them the shots - the nurse had to resubmit an appeal and that was approved.They are both on nebulizers now and get their RSV shots monthly.



    Oh, yeah, Nikola was under 5 pounds when he was born. I wonder WHY they won't approve them now that Nikola HAS bronchiolitis?
    Ours are in daycare and I have a history of asthma.

    Any suggestions of what I can do if their pediatrician says no? I don't want to switch pediatricians because in all other respects she is GREAT...

    is there a way of getting them outside of our healthcare? We have Kaiser...
     
  7. meganguttman

    meganguttman Well-Known Member

    QUOTE(desolation_anonymous @ Feb 4 2009, 05:30 PM) [snapback]1176436[/snapback]
    Oh, yeah, Nikola was under 5 pounds when he was born. I wonder WHY they won't approve them now that Nikola HAS bronchiolitis?
    Ours are in daycare and I have a history of asthma.

    Any suggestions of what I can do if their pediatrician says no? I don't want to switch pediatricians because in all other respects she is GREAT...

    is there a way of getting them outside of our healthcare? We have Kaiser...


    Can you contact the insurance company directly? If they approve it I'm sure the Dr. won't deny it.
     
  8. DATJMom

    DATJMom Well-Known Member

    Sorry that you are going through this. I would contact the insurance company directly to see if you can get anywhere. Mine were covered for the first RSV season.

    Our stipulations were:

    Less than 32 weeks
    Smoker in the house
    Daycare


    We only met one of the criteria and that was that they were born at 31 weeks 6 days. GL!
     
  9. artemis

    artemis Well-Known Member

    QUOTE
    The doctor told me that Kaiser will not give shots of Synagis unless the babies were born under 32 weeks.

    That is not true. The doctors have the ability to bend the rule, it sounds like yours just isn't willing to.

    I know this for a fact because we're at Kaiser and my 34 weekers are getting the RSV shots. I spoke with their 2 main neonatologists when the babies were going home from the NICU. My babies were small and I have an older child at home, so I asked if there was any way we could give them the Synagis shots. The neonatologists conferred about it and decided that there's enough risk factors to justify it, and so the babies have been getting it the shots, Nov-March this year.

    The thing is, Kaiser is only doing RSV shots until next month, because after March the risk of infection goes way down. So even if you were able to talk your doctor into doing it, it's really only another month or so that it's an issue. It's great they've gotten through the majority of RSV season, at least! I hope the boys get better soon, that sounds miserable. :(
     
  10. kingeomer

    kingeomer Well-Known Member TS Moderator

    I'm sorry that you are going through this, I hope they feel better soon :hug:
     
  11. mollyjm

    mollyjm Well-Known Member

    Do you know why? is there a safty issue or is it a money issue for the insurance company? just wondering what the docs motivation might be? if he could, then why wont he if it's what you want?
     
  12. MomofNickandSuzy

    MomofNickandSuzy Active Member

    We were denied initially too. We pushed (a lot) and got approved........our risk factors were: age (33 weeks), multiples, daycare and school age siblings. I would continue to push for it!

    Good luck!
     
  13. melstofko

    melstofko Well-Known Member

    I am in the same boat. I had my boys at 33 weeks and 4 days. They were 5.8 and 5.9 at birth with no respiratory complications. My pediatrician told me that we didn't meet the critieria ( <32 weeks, sibling in daycare, smokers in home, resp distress at birth) he said that he would fight it if I wanted but he didn't think they would need it due to being huge and thriving. Well...all 3 of my little ones have bronchiolitis now and the boys are on albuterol nebs at home. My understanding as a peds nurse who deals with a lot of RSV/bronchilitis is that RSV is just one of the many viruses that lead to bronchiolitis (the end result) or pneumonia. So what they have now is technically one step further than RSV. Remember, in you or I RSV is just typically a cold but to preemies it is harder to handle because of their small airways.I think that if your little ones actually got RSV you could expect the same symptoms with maybe more secretions (if they don't have them already). All we do in the hospital to treat them is albuterol nebs, gently "pound " on the lobes of their lungs (similar to burping them with a cupped hand to loosen secretions), give them fluids, oxygen if necessary, and suction them with saline as needed (generally before feeds and sleep and whenever else they sound congested)


    hearing your story though it sounds like you should be approved for more than one reason. I would call your insurance directly, find out the criteria and resubmit!! I can't believe the insurance companies sometime. I know the shots are expensive but the treatment can be costly as well, esp. if you end up admitted to the hospital. Good luck, I hope your babes get well soon. '

    QUOTE(artemis @ Feb 4 2009, 08:43 PM) [snapback]1176640[/snapback]
    That is not true. The doctors have the ability to bend the rule, it sounds like yours just isn't willing to.

    I know this for a fact because we're at Kaiser and my 34 weekers are getting the RSV shots. I spoke with their 2 main neonatologists when the babies were going home from the NICU. My babies were small and I have an older child at home, so I asked if there was any way we could give them the Synagis shots. The neonatologists conferred about it and decided that there's enough risk factors to justify it, and so the babies have been getting it the shots, Nov-March this year.

    The thing is, Kaiser is only doing RSV shots until next month, because after March the risk of infection goes way down. So even if you were able to talk your doctor into doing it, it's really only another month or so that it's an issue. It's great they've gotten through the majority of RSV season, at least! I hope the boys get better soon, that sounds miserable. :(



    I am in AZ and not with Kaiser but our insurance (United Healthcare) also has the age limit being at 32 weeks
     
  14. glpkkg

    glpkkg Well-Known Member

    We are dealing with a similar situation. The referral nurse at our doctor's office called and said the shots would not be covered for our girls becuase they weren't at high enough risk! She told me to call the insurance and I did. The insurance company told me that according to guidelines they have the girls would not qualify but there had not been an appeal filed yet. They told me to have our doctor file an appeal and provide a letter of medical necessity. The referral nurse just didn't want to have to do any extra work!
     
  15. Fossie

    Fossie Well-Known Member

    It sounds like a crappy situation, but like a pp said - there are now only two more shots that they will give because they end in March and that may be even more reason that they won't do the extra legwork to appeal and get it approved.
     
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