Synagis denials in California external review
In the California DMHC record, independent physician reviewers decided 35 published external-review cases involving Synagisand overturned the plan’s denial in 48.6%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Conditions behind Synagis denials
| Category | Decisions | Overturned |
|---|---|---|
| Respiratory Syncytial Virus Infection | 7 | 71.4% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 27 | 48.1% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 8 | 50% |
What the reviewers wrote
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
Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for the Synagis vaccine. At issue in this case is whether the requested Synagis vaccine is medically necessary for treatment of the enrollee’s medical condition. In 2014, the American Academy of Pediatrics issued new guidelines for the administration of Synagis for respiratory syncytial virus (RSV) prophylaxis based on review of current peer-reviewed literature related to burden of RSV in infants and children with emphasis on those at highest risk of severe disease.
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.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Synagis, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY