Wednesday, March 28, 2012

Great. Just Great.

Last year, Judith got Synagis shots from February through April, no problems (she didn't get her first dose until she was ready to be discharged from the NICU).  This year, we knew we would be approved for the season because of her CF.  So why the hell did I get *that* phone call this afternoon?

Turns out our insurance, which has never given us problems, deemed it no longer necessary for Judith to receive any more injections of Synagis this year, as she has already received 5 doses and it is no longer medically necessary.

Let's see... where to start... I think we'll go with a big ol' eye roll, followed by 2 middle fingers.

Judith's primary pediatrician called this afternoon (well, one of the nurses actually called) and gave me a heads up about the problem because we're supposed to have an appointment for the last injection very soon.  They tried talking to the insurance company, but they weren't having any luck.  So they wanted our pulmonologist to talk to them instead and see if he can get the insurance company to reverse their decision.

6 phone calls later (including call backs from the clinic), I finally got the info to the right person and the doctor to doctor review was going to be happening.

Yes, we are at the tail end of RSV season here, yes, the reports are showing that cases of RSV are dropping, and yes, Judith already received 5 injections this year.  However, the concern lies in the fact that there are still enough positive tests for RSV that Judith's primary pedi is not comfortable with her going without the shots.  I didn't get to talk directly to her pulmonologist, so I'm not sure what his take is on the issue, but I guess we'll find out when the insurance company decides.

Getting the injections out of pocket is out of the question: the shots run on average $1600 per dose.

So what are we going to do?  For now, we're keeping our appointment and waiting to hear what the final decision will be.  If we can win the appeal and get it covered, we're good to go.  If not, that's going to throw a serious loop into our plans for at least the next 2-3 weeks, and we're going to have to be even more anal about people handling her.

This is beyond frustrating.

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