Approved and Denied

It is RSV season again. This is a virus that causes cold symptoms in adults and older children, but can cause serious breathing problems in babies, especially ones who were premature. As you may recall, there is a drug called Synagis that provides antibodies against RSV with monthly injections. Our insurance company approved the boys for Synagis last year (although you may also recall our shock at the $100 copay per injection!)

It is more difficult to get approval for a second year, so I was surprised when the pharmacy company called to inform us that James had not only been approved for a second year, but that the insurance was going to cover the whole cost, with no copay. (In fact, I'm still not sure I believe that!! This is, after all, the same company that gave us the run-around about covering his much cheaper Prilosec.) They approved him because his medical records say that he has chronic lung disease, a diagnosis I still don't completely understand. We've been very lucky in that neither of the boys has had breathing problems since coming home from the hospital, so I can't figure out if the CLD designation is because they actually know something about the condition of his lungs, or because he was on the ventilator a certain amount of time in the hospital, or what. (And I'm probably wrong about this, but I also wonder if the approval was partially because his records indicate that he was hospitalized, even though that hospitalization was for his surgery.) But covering the whole thing like that, assuming the pharmacy rep was correct, suggests they think he's a very high-risk kid. And while I'm certainly not going to argue with providing him that extra protection, it wouldn't necessarily have been my perception of his risk.

Matthew was denied Synagis coverage for this year, so our pediatrician is writing a letter to see if they can get that decision changed. The irony, of course, is that although James has obviously had the much more difficult medical course overall, Matthew seems to be hit harder by cold-type illnesses. So far, when they get colds, Mattie's symptoms are more severe and last longer. (Sorry, kiddo, you seem to have inherited your mama's sinuses!) Mattie is the one that had the cough that lasted for three or four months (and just when I realized it had gone away, we all caught a cold coming home from Colorado, so now he has a brand new cough); he's the one that had to have a chest X-ray, and he's the one that our pediatrician almost referred to the pumonary specialists to check out the cough. I have no idea if this kind of thing relates to how he'd react to an RSV infection, but hopefully we won't have to find out!