Sinigus- RSV Vaccine

My health insurance had approved the Sinigus shots for 12 months, unfortunately I was in Cobra and had to
change to dh. I was just told today that his insurance denied it. My babies were born
at 32.5 days and the cut off date is 32 weeks and since they don't have any older siblings
or attended daycare they don't "meet" the requirements. I am so mad right now!!!
If they get out of the house they would be in contact with other kids just like if
they had an older sibling that went to school or if they went to dayscare...just
going to the dr's office alone they are surrounded by germs....
any ideas on how I can get the insurance to approve this shots?

 

QUOTE(Gimena @ Nov 24 2008, 08:31 PM) [snapback]1085420[/snapback]
My health insurance had approved the Sinigus shots for 12 months, unfortunately I was in Cobra and had to
change to dh. I was just told today that his insurance denied it. My babies were born
at 32.5 days and the cut off date is 32 weeks and since they don't have any older siblings
or attended daycare they don't "meet" the requirements. I am so mad right now!!!
If they get out of the house they would be in contact with other kids just like if
they had an older sibling that went to school or if they went to dayscare...just
going to the dr's office alone they are surrounded by germs....
any ideas on how I can get the insurance to approve this shots?



I remember the nurses in the NICU telling us that if our insurance denied it to fight it, because since my twins were born at 34 weeks, they were indeed eligible. We had no problems.

If I were you, I'd enlist the help of either your pediatrician or OB or NICU staff.

Good luck.

 

I'm sorry you have to deal with this. I agree with the PP. I'd talk to your doctor to see what strings he/she can pull for you. I'd also file an appeal with your insurance company. There should be instructions on how to do that on the denial letter you got.

Mine were born at 34 weeks, had low birthweight and were in day care--they qualified.

 

My girls were born at 29 weeks so I was SHOCKED when I was told we had been denied. The respiratory therapist at our ped office had already appealed it when we found out. I called the insurance company (bc/bs of mississippi, catalyst is the pharmacy part) and they said it was because they were over 6 months old. Our pedi didn't seem too happy about this either and checked and said that another doctor, a cardiologist we had seen once with Hannah, said she didn't need it. I called the insurance company again to see if I could fight it more and when the lady called back she said they had both been approved. I'm assuming we're approved for the whole course of shots... I would fight it though, does your pedi know about it? My thinking is they should be willing to fork out the money for shots instead of for a hospital stay.

 

I have heard of some calling the maker of the vaccine and seeing if they could help. They hate bad press of any sort and insurances denying coverage of a product is just that. I work in a hospital and have seen people win coverage because they kept persisting. Good luck! :hug:

 

Our guys were born at 34 weeks and were in NICU (had TTTS) for 1 week and 2 weeks. We were approved by our coverage with United Healthcare, but we're shelling out $200/month for the shots. I think the pharmaceticals and insurance stuff is messed up on this RSV Synagis issue. . . they scare you to death telling you that your preemies need this, then they gouge you.

I don't know what to think.

 

Mine were denied too! I appealed and had the doc write a letter and call and the insurance company still denied it. This went on for months so I guess we are going without. My pedi tried to reassure me but I am soooo UPSET!!!! I wish you luck, fight it for sure!

 

My boys were born at 36 weeks, 5 days (which is not that early), but my pedi said they should qualify because they had several risk factors including being twins, TTTS and going to day care at 7 weeks old. Pedi filed the paperwork to see if we qualify and the local Children's hospital called me to tell me that since the boys do not have any pre-exsisting lung issues, we did not qualify for the vaccine. I was pretty upset and I still am because I am worried sick about my little guys!

Based on what I have read here, I think I am going to try to fight it and see what I can get done!

 

I just fought with my insurance company and finally won after the second appeal....they denied us at first saying my twins didnt qualify.....they were born at 30 weeks, they have older sibling etc.....after meeting with them at a hearing....there dr repeatedly said mine werent qualified because they have to be 6 months or younger at the time of rsv season which in there books its Nov.....it was so silly but our presentation to the board was that Rsv season started Nov. 1 which my twins were 6 months at that time and wouldnt be 7 months on Nov. 4.....but no matter what we were not giving up on fighting....between meetings, phone calls and notifying tv stations we finally got approved.....twins got there first round last week....DONT GIVE UP






QUOTE(Gimena @ Nov 24 2008, 09:31 PM) [snapback]1085420[/snapback]
My health insurance had approved the Sinigus shots for 12 months, unfortunately I was in Cobra and had to
change to dh. I was just told today that his insurance denied it. My babies were born
at 32.5 days and the cut off date is 32 weeks and since they don't have any older siblings
or attended daycare they don't "meet" the requirements. I am so mad right now!!!
If they get out of the house they would be in contact with other kids just like if
they had an older sibling that went to school or if they went to dayscare...just
going to the dr's office alone they are surrounded by germs....
any ideas on how I can get the insurance to approve this shots?