Qualifications for RSV Prophylaxis - Synagis

Admins: Could you place as a sticky? Many parents out there are learning about RSV preventative injections, Synagis, but it seems that there's not a lot of direct information out there about what the qualifications are for receiving them. I've compiled a list of some of the requirements children must meet in order to become eligible for insurance company approval. This list may not list every factor each individual insurance company considers, so make sure you check with them to see if they have other qualifications. Factors: 1. Age * Gestational Age/Premature birth - 35 weeks of gestation or earlier, but only with additional risk factors * Chronologic age at the start of the RSV season * Younger than 24 months of age - Infants born at 28 weeks of gestation or earlier may benefit from prophylaxis up to 12 months of age; infants born at 29 to 32 weeks of gestation may benefit most from prophylaxis up to 6 months of age. Children over this age may have to meet other requirements in order to receive approval. 2. Weight * Birth weight * Percentile on the growth chart * Underlying conditions causing low weight 3. Health Factors * History of severe and/or chronic recent respiratory illness - Children with chronic lung disease (CLD) who have required medical therapy for their CLD within 6 months before the anticipated RSV season * History of recent respiratory distress * Health conditions dependent upon respiratory therapy or medications: eg - oxygen, albuterol, steroids, trachiotomy, suction, and/or other respiratory equipment dependency * Health conditions that show substantial risk of future respiratory distress - Chronic lung disease (CLD) - Pulmonary Hypertension - Asymptomatic acyanotic congenital heart disease (CHD): eg - patent ductus arteriosus or ventricular septal defect * Immunocompromised children - immune system deficiencies: eg - severe combined immunodeficiency or severe acquired immunodeficiency syndrome 4. Costs and Other Factors * Risk of hospitalization cost compared to prophylaxis cost * Underlying conditions that predispose to respiratory complications (eg, neurologic disease in very low birth weight infants, lung development) * Number of young siblings * Child care center attendance * Exposure to tobacco smoke in the home * Anticipated cardiac surgery * Distance to and availability of hospital care for severe respiratory illness * Fragility of the medication itself - must be used within 20 minutes of mixing, must be transported and stored under strictest conditions, availability to health care provider, etc. * Doctor recommendation and/or Letter of Medical Necessity. Most, if not all, insurance companies require all children tthat receive Synagis to have precedence of respiratory illness, risk of future distress, and respiratory therapy dependency of some kind before they will even consider the other factors. It is not enough to simply be of the right age, weight, and have a gestational period of less than 35 weeks. RSV is dangerous to all children, especially premature babies, but it seems that the insurance companies want to reserve it for those who have chronic respiratory issues and are at future risk of distress.

5 Replies

  • we had a very hard time getting the insurance to cover lilys synagis this last year and the way things are going i know she will need the shots again ,and i also know that it will be another long fight,I found the best thing to do is anoy them all the time,call dasily,talk to supervisors,talk to whoever until they give in (and they will give in)for if no othetr reason just to get rid of you,I have done this several times and have never been denied after getting on their cases,you have to make them see your children as people not as member #s ,I hope this helps you a little good luck .
    Thank you, thank you, thank you, times 3.
    This is invaluable info for me in my quest to overrule United's decision to not cover my triplets born at 28 weeks.
    If you find anything else, please forward it.

    My direct email is : cjmarketing@aol.com


  • Year 'round RSV
    I found a couple of links that DO indeed state that RSV, esp. in Florida, are year 'round:

    RSV epidemics year 'round
    "RSV outbreaks occur each year on a fairly predictable schedule that varies from one region to another. In the United States, the RSV epidemic "season" usually begins in the Fall, and lasts through Spring. However, in some parts of the United States, such as Southern Florida, year-round epidemic levels have been seen."

    Respiratory Syncytial Virus No Longer Seasonal
    "A new study has documented an ongoing, nonseasonal epidemic of respiratory syncytial virus (RSV) among children in the southeastern US, challenging the general conception of RSV as a seasonal condition that peaks in the winter months.

    "Researchers report that of 5000 fresh nasal aspirates or washings collected year-round from pediatric patients in large southern hospitals during the period from May 1993 to December 1996, 28% were positive for the RSV antigen. The report appeared in the May issue of the Southern Medical Journal (1998; 91:433-436).

    "The authors label their findings "a persistent epidemic," defining epidemic as 2 consecutive months in each of which at least 10% of specimens were positive and at least 2 positive specimens were detected.

    "Health authorities are recommending that clinicians, especially those in the southeastern US, consider RSV year-round in the differential diagnosis of acute respiratory illness in pediatric patients."

    Year 'round RSV in equatorial regions
    "Unlike influenza, which tends to have severe epidemics every 10 to 15 years with a short peak period, RSV incidence is regular and substantial occurring every year during the winters in both the Northern and Southern Hemispheres and virtually year round in equatorial regions."

    Florida Dep't of Health - RSV Surveillance
    "Although RSV is present year-round in Florida, peak activity is detected in the winter months. RSV is considered to be widespread when at least 10% of all specimens tested for RSV during a surveillance week are positive. In Florida, the Department of Health’s RSV Surveillance System monitors RSV activity at the state, regional and local levels. RSV surveillance began in October 1999 for the North, Central, Southeast, and Southwest regions of the state and in January 2001 for the Northwest region. The RSV Surveillance System is an essential component to the statewide effort of preventing and controlling RSV year round."

    Bureau of Epidemiology, Fla Dep't of Health Data
    This page shows a chart of data collected; the Southeast (in bright blue) peaks year around over the 10% guideline that the US Dep't of Health uses to track RSV epidemia. As you can see, it is always well over 10%, yet overall peaks less often than other US regions. This simply means there is a steady epidemia of RSV infections throughout the Southeast states.
    Do you have info that shows that RSV season is year round? I am located in FL and United Insurance wont cover Synagis for my triplets as they say its not year round. In Fl it is, according to my Dr.


  • Hi and thanks for posting; welcome to Share!

    My name is Darcy and I am the Share Your Story Community Coordinator. I saw your request, "Admins: Could you place as a sticky?" and wanted to let you know that the site format is that discussions most recently posted automatically bounce to the top of the list. All discussions stay active unless there is no post for 6+ months. Unlike a typical bulletin board format, there is not a "sticky" protocol; conversationS with the most participation filter up automatically.

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