I have already received a lot of feedback from people who have received their first denial letter wondering if they should use my template to appeal. My answer is always appeal. Did you know that some insurance companies automatically deny Synagis (and other drugs) with the first applications. Yes, an automatic denial never mind how sick your baby is or how many criteria they satisfy. They do this because they know launching an appeal will just be too difficult for some parents. It is just evil.
In the last post I covered Synagis appeals, but left out a few special situations as there is only so much information I can put in one post!
Here are some special situations:
My baby has Medicaid:
In many states Medicaid uses the AAP guidelines (from the 2009 Redbook) so an appeal may also be needed. The big advantage of Medicaid? There should be no automatic denial if your baby meetings the AAP guidelines. However, as MEdicaid varies state to state, what they cover and what they don’t can vary significantly. Use the same wording as the letter from yesterday that best suits your baby’s situation (recap: the 1rst letter is for a baby that meets the AAP guidelines and the second letter is for a baby who does not meet the AAP guidelines) but instead of ccing the State Insurance Commissioner send a copy of the appeal letter to the State Medicaid Director (use the link to find the name and address for your state).
What if your baby was approved for 1-2 shots and you want the full 5? This is most likely to happen for babies 32-35 weeks.
Following the same instructions from the previous post on meeting all the appeal deadlines and sending a cc to the State Insurance Commissioner (or State Medicaid Director) and use this wording for the body of your letter:
Thank you for approving 2 doses of Synagis for my son John Doe. As you know he was born prematurely at 33 weeks gestation. He spent 3 weeks in the NICU and is now 7 weeks old. His older brother attends day care.
I am appealing the decision to only given him 2 doses of Synagis. An article by Boyce TG et. al. (from the Mayo Clinic), published in the Journal of Pediatrics in 2000, indicates that all premature infants born at 36 weeks or less are at increased risk for hospitalization due to RSV in the first year of life. The risk of hospitalization is 57/1,000 for babies born at 33 to < 36 weeks, which is almost double the rate for children born at term (30/1,000). The two year prospective PICNIC study (Wang EL, et. al. Journal of Pediatrics 1995) also confirms that relative to infants born at term, in the first year of life, babies born at 36 weeks or less are at increased risk for hospitalization related to RSV and premature babies born between between 33 and 36 weeks are two and half times more likely to need mechanical ventilation compared with a baby born at term.
In addition, the practice of limiting Synagis to less than 5 monthly injections is completely untested in prospective clinical studies and is not supported by the pharmacokinetics and therapeutic efficacy of the drug (IMpact-RSV Study Group trial, Pediatrics 1998 and Saez-Llorens et al. Pediatric Infectious Diseases 1998).
RSV season is here and so I expect to receive your approval for an addition 2 doses of Synagis within 5 business days,
One final point. Some parents are worried about launching an appeal and having the already 1-3 vials of Synagis retracted or denied. I have never heard of that happening, but you never know with insurance companies. Obviously you have to make your own decision about when and if you file an appeal. If your original vials are based on the AAP 2009 Redbook Guidelines then the chance of those being retracted should be zero, but of course I can’t make any guarantees. That, of course, highlights the problem with insurance companies – you pay your money and you still don’t get guarantees.
Best of luck. Please post success stories or problems!
Remember, this blog is not direct medical advice