We have Anthem insurance and they are denying the Synagis shots. Grrrr. I'm actually on hold with them right now. I'm fighting this one!
QUOTE(Mum2TwinBoys @ Feb 29 2008, 12:47 PM) [snapback]646778[/snapback] Absolutely fight it, damn insurance companies. ours covered ad small portion of it. we ended up paying approx 500 for each time. it bites to pay that much. i had to remind myself with all the medical costs that we will get tax refund +O
Fight it and fight hard, I used to work for an HMO and I hated it. One time I had a member on the phone who was in his 80's and he was trying to care for his father who was 106. The dad broke his hip and was in a skilled nursing facility. The "lovely"(I say that sarcastically) HMO I worked for had the brilliant idea of wanting to send Dad home to the care of his children, all of whom were in their 80's. Hello???? I said to the member's son, let's file an appeal and tell me everything no matter insignificant (I was angry that the company could be that heartless) and the appeal did overturn the decision to boot dad out of the nursing facility. So file an appeal, tell them everything and good luck!
Good luck! I had to fight too to get my 34 week 2 day twins the Synagis shots. We only qualified because one of my daughters had oxygen in the hospital for four days. I think after 34 weeks babies have to have two "risk factors" or a medical condition. If your twins were healthy you may not qualify (sadly).
our insurance company told me that unless mine were prior to 34wks or had RDS they didn't qualify since my twins were neither (but very low birthweight) they didn't get them - and neither of them got RSV...
I had to fight mine with an appeal. We had to add that my friend who has a school age child helped to take care of them in addition to the fact that my husband smokes and they were 33 weekers. It was so frustrating. They then agreed to cover the shots but they only cover 80% which leaves us with 309.00 per child. With 5 shots that is a ton of money but luckily we got approved for up to 1,500.00 a child in assistance from a non profit organization called Patient Access Network Foundation. Good Luck, I hate dealing with Insurance companies!!
QUOTE(Trishandthegirls @ Feb 29 2008, 01:03 PM) [snapback]646806[/snapback] Good luck! I had to fight too to get my 34 week 2 day twins the Synagis shots. We only qualified because one of my daughters had oxygen in the hospital for four days. I think after 34 weeks babies have to have two "risk factors" or a medical condition. If your twins were healthy you may not qualify (sadly). Ours denied it even though they were 34 weeks exactly, under 2000g at birth, and Meara was on oxygen for 1 day (just CPAP). I fought hard, but in the end they denied all the appeals because they weren't preemie enough. To the OP, do fight it and have your pedi call on your behalf too. Did your get it in the NICU? When does RSV season end for you? GL and keep us posted.
Ooo Ooo Ooo girl fight it!! Ours is Blue Cross Blue Shield and they tried Denying us too! DH fought with them and they paid for them in full AND reembursed us for the one month WE had to pay out of pocket. He had them though because before the babies were born he called and asked if those shots were covered and the nice lady he talked to said, "why yes sir they are 100% for twins, preemies or babies with older school aged children." (ours were all three) So two months later they wont pay and my Dh says, "hey didnt you all tell me that these calls are all recorded?" "yes sir" "then go BACK and listen to the call when I was told my kids would be covered, the call took place on 'such and such a date'." LOL Sure enough they went back through the recorded calls and we were given our coverage!!! If your babie are twins, preemie or have older siblings I believe ALL insurance companies say they will cover.
Ours were denied, too, even though they were 35 weeks, and Kevan has laryngomalacia, a condition that already strains his breathing, so he absolutely CANNOT risk getting a respiratory illness. And, we have an older child that attends preschool -- lots of risk factors, IMHO. When does RSV season end, does anyone know? I'm wondering at this point if I should keep fighting -- my munchkins are almost 9 months, and I figure the season can't last much longer...thus far, they've been healthy, and have only had a couple minor colds. Is it worth it try to get shots for the next couple months?
QUOTE(7Ms @ Feb 29 2008, 11:38 AM) [snapback]646882[/snapback] If your babie are twins, preemie or have older siblings I believe ALL insurance companies say they will cover. Actually, this is the first year that the guidelines for RSV do not include twins. In previous years, just being a twin was a risk factor. This year it isn't. Also, this year the guidelines state that babies before 33 weeks should be covered with no questions asked, and those 33-34 weeks covered if they have one risk factor, 34-35 weeks covered if they have two risk factors (smokers, day care, older siblings in school, etc.), babies 35+ not covered unless there's a medical condition. Insurance companies don't have to follow the guidelines, but apparently most do. I forget who publishes the guidelines, but it's the American Academy of Pediatricians or something like that. Here in NM I think RSV season is ending in April. My girls will get a shot this coming Monday and then one at the beginning of April.
RSV season ends in March-at least that's our last shot and we've been getting them since October. I think each insurace company is different. My babies were born at 35 weeks, 6 days and none of the risk factors mentioned in pp apply to us. I'm a SAHM with no drinkers/smokers in the home. All we pay is $40 co-pay per shot.
RSV season does not end in MT until JUNE!! Check with your pedi about when it ends. Mine were 35 wks and were covered after a long battle (see my previous post)
2 hours on the phone and nada. The nurse who finalized the denial of my claim said that they didn't have enough risk factors and it wasn't "medically necessary". I told her I work in an NICU and I think we would all agree that RSV shots should be "medically necessary" for every child and I've taken care of RSV babies with less risk factors than my twins. I'm tempted to call back and say that my husband decided to start smoking today. That would give us another risk factor. Sad. My sons both had RSV and have problems every time they get an Upper Resp infection, etc. it always ends up wheezing or croup, have to do steroids. . . ' She asked if there was anything else she could do (I refrained from saying what I really thought) and told her that she could maybe be of assistance when we started filing claims when they are hospitalized with RSV later on.
WEll that sucks, I am sorry. Health insurance, What a friggin' scam. Sorry I am ina bad mood today anyway and this just pisses me off for you! :blush:
Well thank you! It IS a scam, isn't it? It makes me mad that some lady sitting at a desk can sit there and smile through the phone and stamp DENIED on our claims without even understanding the situation. I'm going to call the Dr I work with and see if he has any suggestions. I've heard him yell at a lot of insurance companies over the phone on this one over the years.
Sorry about all of this stress. You must be exhausted by now. Try and have your ped call. Often they're more effective then us. I know how important those shots are. My boys had breathing issues--intebated, cpap, so rsv scares me. ( they do get them) Good Luck Lisa
