Why do they get to decide?

I have a good friend who is fighting her insurance company over a vaccine that can keep her daughter from becoming quite ill. The company is denying her because of her age (she will 3 next week). Her daughter was born with hypoplastic left heart syndrome and faces what we all hope is her last surgery in 6 months. The vaccine is Synagis. Monkey is receiving this medicine and our insurance did not even bat an eye in approving it. The only reason he qualified is because is was 5 wks early and a multiple (I find it ironic that this still carries weight considering Noah is no longer with us). He doesn't really have a chronic health issue that would typically be considered for Synagis. We are just very lucky that our insurance company is very lenient about this vaccine. This is our 3rd and final RSV season that we will receive the shots.

My friend has appealed and had it denied. How can an insurance company override the decision of the pediatrician? He felt it was in her benefit to receive the shots, yet the insurance company doesn't want to foot the bill, so they just deny it. It has gone on to the next level of appeal, but in all honesty the RSV season will almost be over before anything is decided. This is so wrong. I don't think a money hungry industry should get to decide whether a treatment is needed. That is the doctor's place. I also find it ironic that the insurance companies push you to use their in network doctors, but do not actually trust their opinion if they do not want to pay a claim.

I know some will say that if she really needs the shots, the family should simply pay for them. The shots are over $6,000 a shot for a child her age. With six shots a season, that is $36,000. Who has that kind of cash lying around? It is not feasible for a normal, working family to afford such things without their health insurance.

There is so much talk about health care reform (and I am not expert), but all I hear about is the cost of premiums. I know that this is an issue, but what about the individuals not receiving care that doctors deem necessary? I know that children with Medicaid in our state who are recommended to receive the shots are not always approved. Just the other day a Mom was at our pediatricians office with her premature baby and had been denied by Medicaid. I guess the insurance companies would rather take a gamble with a babies health and just pay the hospital bills.

It all just seems wrong. While I am grateful for our insurance company paying for these, we have ran into other items that they will not pay for. Monkey was referred for a cranial remolding band as a baby due to plagiocephaly and torticollis. They would not pay the $1500 the band costs because they deemed it cosmetic. Plagiocephaly can cause vision and other problems. It is more than cosmetic. We were fortunate that we could afford it. They also have limits on OT, PT, and speech therapy. We have used all of these services or still are for Monkey's developmental delays. My ability to pay out of pocket for these services will affect my child's future. I just don't get how someone in an office somewhere gets to decided what is best for my child. I will definitely be paying more attention to these topics than I did before.