I feel your pain!Unfortunately, I don't know if you know, but there's more to receiving Synagis than just having a preemie. There are many factors that depend upon whether your doctor can even make the argument that your child needs Synagis, and it doesn't sound like your son qualifies.
First and foremost, your son has to have had a history of repiratory distress, not just a prior respiratory illness, be dependent upon respiratory therapies (like oxygen or albuterol, etc.), plus a history of other illnesses (generally since birth or shortly thereafter) that potentially puts him at risk currently (scarring on the lungs due to pneumonia, cystic fibrosis, etc.). They also have to be currently underweight, even on a preemie growth chart (I think it's below the 20th percentile, but don't quote me), and are to be deemed at substantial risk in the future.
I am not defending the insurance company, please believe me, but it does have to justify $1800-$2500 PER VIAL of the stuff retail price when she got the shots. (My daughter required TWO vials for the last two years; we accidently received the bill one time for it, and it was like $5,000!) I think they weighed the cost of the Synagis against her previously incurred $2 million dollar health care bills up until she was three years old, and decided that it was cost effective for the prophylaxis Synagis than another heart surgery or a 90-day ICU stay...Unfortunately for other patients, it's not as cut-and-dried, since not every patient that SHOULD qualify is as sick as my daughter was.
She got the shots every year until she was four years old, and the final year she received them was a huge battle, even with her history. Lauren qualified during those times because she was a born a preemie (32 weeks) - 4 lbs. 2 oz. - with respiratory distress, was/is within the 5th percentile with her weight; she was born with Down Syndrome, has a lowered immune system, adelectisis of her right lung, and a heart defect; she contracted pneumonia 6 times before she was 9 months old, and several more times after, and became oxygen dependent AND relied upon Albuterol, she has substantial scarring (fibrosis), plus she has pulmonary hypertension, has 1/10th of the alveoli in her lungs that normal lung tissues have - most biopsy samples have 20-30 per slide; Lauren had 2-3 per slide! She also was born with a avio-ventricular canal defect (big hole in her heart), which required surgery at 4 months old, and then another heart surgery to repair her mitral valve due to endocarditis (bacterial infection in her heart due to pneumonia) at two years old, when we spend 3 months in ICU.
In Lauren's 3rd year, she went almost an entire year without getting any illness, and they tried to cut her off. So even though the doctor said she still qualified for it, because she hadn't gotten sick in nearly a year, they still tried to discontinue it. We fought it the that time (when she 3, going on 4) and won. The next year, she had not gotten anything except a small cold, and even though we were sure she still qualified, we fought it and lost (that year she was 4, going on 5).
So if my daughter, with all her issues (she's 7 now, and still only weighs only 32 pounds), requiring oxygen while sleeping, and sometimes while awake (her oxygen saturation on room air while awake is about 93-94%), and she can't get it, then I'm not surprised that other's are being denied, especially those without a history of respiratory illness AND distress, plus a huge risk factors of future illness and distress.
They need to find a way to lower the cost, that's for sure! I put together a list of factors that the insurance companies consider when Synagis is requested for a child on this thread:
Qualifications for RSV Prophylaxis - Synagis Good luck to you all! :)