My baby was born 10/10 and got her RSV vaccine on 10/16. BCBS of MS denied it saying it was not preventative. Her doctor is very pro vax (as are we so I love that) so she reached out to BC on our behalf to understand the claim, and they said that it was denied because she got it at six days old instead of eight days old.
Has anybody heard of that? Do we have a leg to stand on? Would it be the doctor’s fault that she “gave it early“? They are trying to say we owe $636 for it.
RSV Vax Denial – BCBS of MS
byu/EndInternational1499 inInsurance
Posted by EndInternational1499
3 Comments
I’d start with contesting it to get their official stance in word format.
From there it goes to was the service given done per schedule or not. Most insurance has a window for things, but some things it can not be early. I.e. my yearly physical is free if it occurs 366 days after my previous physical.
I work for a bcbs entity. Most insurance companies follow the cdc schedule. Did you receive the vaccine while pregnant? If not, i would appeal the claim and reference the cdc immunization schedule
https://www.cdc.gov/rsv/vaccines/protect-infants.html
These are the [CDC’s recommendations for RSV](https://www.cdc.gov/rsv/hcp/vaccine-clinical-guidance/infants-young-children.html) for your review.
Given that the CDC and the AAP(https://publications.aap.org/pediatrics/article/156/5/e2025073923/203221/Recommendations-for-the-Prevention-of-RSV-Disease?autologincheck=redirected) recommend that infants born during the RSV season (September to March) receive RSV immunization within 1 week of birth, your daughter’s doctor did not administer it “too early”.
If your daughter was a full-term birth, you were likely passed the recommended weeks of gestation (32-36 weeks) to receive the maternal RSV vaccination (Abrysvo) in the months of September to January.
If that’s the case, you may want your OB and your daughter’s doctor to each write a letter of medical necessity by describing how/why the purpose of given the RSV vaccination is to prevent RSV-associated respiratory tract disease in infants when maternal vaccination was not indicated/performed. You may also want to contact your state’s [Department of Health](https://msdh.ms.gov/page/14,13899,71,439.html) to see if they would provide a statement that given the RSV immunization at 6 days old is a preventative measure. You should also make sure that your daughter’s pediatrician also includes that your daughter receiving the monoclonal antibody was for preventative purposes and not therapeutic (e.g. as it obviously wouldn’t be considered treatment if she hadn’t been diagnosed with RSV).
Good luck trying to appeal your insurance company’s denial.