Dylan vs. Insurance

Late this summer I got a call from the pediatrician's office asking if we were interested in getting the synagis shot (if you're unfamiliar with what the synagis shot is, it's a vaccination to help prevent RSV for those who qualify for it, given every 30 days) for Dylan again this year. Assuming that his cardiologist would recommend it again this year and remembering that the information on the shot had said that it is recommended for kids with heart defects until they are 2, I said yes. About a month ago I got another call from them to verify the insurance information. The nurse who is over getting insurance approval and keeping track of which kids get the synagis shot told me that thus far the insurance had been claiming no record of him and would resubmit the information to the insurance to get approval. This is a vaccination that is quite expensive so one typically doesn't get it without that approval.

At Dylan's last appointment with his cardiologist, he asked if he was getting the synagis shot. I told him we were still waiting on approval. He said that if they are having a hard time getting him approved to have them let him know and he would be happy to write a letter to the insurance company to try to get it approved because it's something he thinks he should have.

After a bit of not hearing back about it, I decided to call the pediatrician's office and ask about it and let them know about what his cardiologist had said. The nurse told me she would call them and see if she could find anything out and call me right back. She called me back shortly and told me that she had just received a fax from them requesting more information about his heart. She said she thought it would be a good idea to have the letter from the cardiologist to send along with that information and had me call him and ask that he fax her the letter so she could send it with the information she had to send.

Last week she called me again. She said that the insurance company denied the request for him to receive the shot, sent it immediately to appeals and denied it again, even with the letter. Apparently they've changed the parameters for those who receive the shot just in time for this cold and flu season, and he no longer fits in their parameters. She did send me a copy of the denial letter she had received. The reasons the letter states for denial are that he was full-term and post cardiac surgery, he is in his second RSV season and non on any cardiac medicines. Says he has "no CLD or other risk factors" and does not meet the "medical necessity criteria."

Don't ask me what CLD stands for. I have no idea. All I know is that I'm a little bit annoyed that they've denied him because I know how easily he seems to catch everything that comes around. Which is why we are keeping him home as much as we can, especially from places with large groups of people. We will take him to a few things like Emma's baptism. Of course, I'm thinking the question of taking him to the ward Christmas party and a wedding tomorrow (which I thought was a bad idea) isn't up for debate any longer. Dylan looked flushed tonight and I felt his forehead and it was warm. Took his temperature and sure enough, he has a fever. I'm thinking it's my fault. I've forgotten a few times in this bitterly cold weather to have his sisters use hand sanitizer or wash their hands before touching him after school and preschool. But then no one else in our family has had fevers recently. Par for the course, he seems to be starting this one. I am so looking forward to spring and summer.