RSV and Synagis QuestionHi Elizabeth - Recently this was posted by chynathedragon. I believe that there are many factors as follows - but most importantly - was / has your baby been sick? Good luck,
Pam
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.