Respiratory Syncytial Virus Infection: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for Synagis (palivizumab). The American Academy of Pediatrics (AAP) guidelines for the administration of Synagis for respiratory syncytial virus (RSV) prophylaxis are based on a review of current peer-reviewed literature related to the burden of RSV in infants and children, with an emphasis on those at highest risk of severe disease. The administration of Synagis is recommended for the following groups of patients considered at highest risk: infants born before 29 weeks of gestation younger than 12 months of age at the start of RSV season; infants with chronic lung disease of prematurity born before 32 weeks of gestation during the first year of life, with some consideration during the second year of life if continued medical support is necessary; infants 12 months of age or younger w…

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synagis (palivizumab) injection. The patient is over the age of 24 months and has a history of severe respiratory syncytial virus (RSV) infection with prolonged respiratory failure. According to Pediatric studies, the administration of Synagis (palivizumab) injection for children in their second year of life is supported in pre-term infants with chronic lung disease that requires medical support such as chronic corticosteroid therapy, diuretic therapy, or supplemental oxygen. Although the patient does not require medical support, the patient did have a prolonged stay in the pediatric intensive care unit (PICU) for RSV which required intensive oxygen support and steroidal treatments.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for Synagis (palivizumab) given once monthly during respiratory syncytial virus (RSV) season. As noted by the American Academy of Pediatrics (AAP) and American Academy of Pediatrics Bronchiolitis (AAPB), RSV prophylaxis with Synagis (palivizumab) may be appropriate for preterm infants who are in the first year of life at the start of the RSV season and who have chronic lung disease of prematurity to a maximum of five monthly doses. Chronic lung disease of prematurity is defined as infants with gestational age less than 32 weeks and a requirement for greater than 21% oxygen for at least the first 28 days after birth. For infants born during the RSV season, fewer than five monthly doses may be needed to complete the RSV season.

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for Synagis (palivizumab) given once monthly during respiratory syncytial virus (RSV) season. As noted by the American Academy of Pediatrics (AAP) and American Academy of Pediatrics Bronchiolitis (AAPB), RSV prophylaxis with Synagis (palivizumab) may be appropriate for preterm infants who are in the first year of life at the start of the RSV season and who have chronic lung disease of prematurity to a maximum of five monthly doses. Chronic lung disease of prematurity is defined as infants with gestational age less than 32 weeks and a requirement for greater than 21% oxygen for at least the first 28 days after birth. For infants born during the RSV season, fewer than five monthly doses may be needed to complete the RSV season.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for respiratory syncytial virus infection was denied, the published record says the denial is worth fighting.