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Insurers deny 25% of medication claims for infant respiratory illness

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A drug used to reduce severity of a common respiratory illness among infants is denied a quarter of the time by commercial insurers even if patients qualify for its recommended use, according to a new analysis. 

Respiratory syncytial virus, or RSV, contributes to about 57,000 hospitalizations among children younger than five each year in the U.S. Virtually all children will get the infection before they are two and most of the time the symptoms are mild but in severe cases it can lead to bronchiolitis or pneumonia. There is no vaccine for RSV but the medication palivizumab is recommended for use by the American Academy of Pediatrics among infants born before 29 weeks or infants with congenital heart disease or chronic lung disease because they are vulnerable to severe cases of the virus. 

Despite its recommended use, 25% of palivizumab prescriptions for babies born before 29 weeks gestation were denied by commercial insurers from January to December 2019, according to a report from the not-for-profit Institute for Patient Access. The analysis includes 1,031 commercial claims.

Furthermore, 14% of 2,309 Medicaid claims for palivizumab prescriptions for babies born before 29 weeks were denied during the same time period. 

“Those faced with the challenge of bringing home a preemie or at-risk infant have enough on their mind. They shouldn’t have to fight their insurance company for a medication that can protect their baby from complications of infectious disease,” said Dr. Mitchell Goldstein, medical director of the National Coalition for Infant Health, in a statement. 

The cost of palivizumab is variable, ranging from $3,221 to $12,568, according to a 2017 studylooking at Medicaid claims.

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