By Counterforce Health Team in Synagis (palivizumab) —

How to Get Synagis (Palivizumab) Covered by Humana in Washington: Complete Authorization & Appeals Guide

Answer Box: Getting Synagis Covered by Humana in Washington

Synagis (palivizumab) requires prior authorization from Humana for high-risk pediatric patients during RSV season. Your fastest path: 1) Confirm your child meets AAP high-risk criteria (≤35 weeks gestation, chronic lung disease, or congenital heart disease), 2) Have your pediatrician submit Humana's prior authorization form with complete medical records, 3) If denied, file an internal appeal within 65 days, then request external review through Washington's Independent Review Organization. Washington residents get strong consumer protections and free advocacy through the Office of Insurance Commissioner at 1-800-562-6900.

Table of Contents

  1. Understanding the Denial
  2. Fixable Causes Before You Appeal
  3. First-Level Internal Appeal
  4. Peer-to-Peer Review Strategy
  5. External Review in Washington
  6. Medical Necessity Letter Template
  7. Tracking Your Appeal
  8. When Appeals Fail: Next Steps
  9. FAQ

Understanding the Denial

When Humana denies Synagis coverage, your denial letter will contain specific reason codes. The most common reasons include:

  • Outside labeled high-risk groups: Child doesn't meet AAP criteria for prematurity (≤35 weeks), chronic lung disease, or congenital heart disease
  • Duplication with nirsevimab (Beyfortus): Already received RSV prophylaxis this season
  • Insufficient documentation: Missing cardiology/pulmonology consultation or medical necessity justification
  • Exceeding dose limits: Requesting more than 5 monthly doses per RSV season

Your denial letter will specify appeal deadlines—typically 65 days for Medicare Advantage plans. Mark this date immediately and gather your documentation.

Fixable Causes Before You Appeal

Before filing a formal appeal, check if your denial stems from easily correctable issues:

Missing Documentation

  • NICU discharge summary showing gestational age and complications
  • Current pediatric cardiology or pulmonology consultation notes
  • Recent growth charts and vital signs
  • Documentation of ongoing medical therapy (oxygen, bronchodilators, diuretics)

Coding Issues

  • Verify ICD-10 codes match your child's diagnoses (P07.3 for extreme prematurity, Q20-Q28 for congenital heart disease)
  • Ensure HCPCS code 90378 is used for Synagis administration
  • Confirm dosing calculations based on current weight (15 mg/kg monthly)

Policy Misunderstanding

First-Level Internal Appeal

Timeline and Process

Humana must respond to internal appeals within 7 calendar days for Part D drug coverage or 30 days for medical coverage. For urgent cases where delay could jeopardize your child's health, request expedited review—Humana must respond within 72 hours.

What to Include in Your Appeal

Required Documents:

  • Original denial letter with claim numbers
  • Updated medical necessity letter from prescriber (see template below)
  • Complete medical records supporting high-risk status
  • Specialist consultation notes (cardiology/pulmonology)
  • Documentation showing nirsevimab is inappropriate or unavailable

Submission Methods:

  • Online: Humana member portal
  • Fax: 877-486-2621 (verify current number)
  • Mail: Address provided in your denial letter

Appeal Letter Structure

Start with: "I am formally appealing the denial of Synagis (palivizumab) for [child's name], member ID [number], dated [denial date]."

Include these key points:

  • Specific high-risk diagnosis with ICD-10 codes
  • Clinical rationale for RSV prophylaxis necessity
  • Documentation of specialist recommendations
  • Explanation of why alternatives are inappropriate

Peer-to-Peer Review Strategy

Request a peer-to-peer review where your child's pediatrician speaks directly with Humana's medical director. This often resolves denials faster than written appeals.

Scheduling Tips:

  • Call Humana provider services to request peer-to-peer
  • Have your pediatrician prepare talking points about your child's specific risk factors
  • Schedule during business hours when pediatric specialists are available for consultation

Key Discussion Points:

  • Gestational age and birth complications
  • Current respiratory or cardiac status requiring ongoing medical management
  • Risk of severe RSV disease based on underlying conditions
  • Why standard alternatives (nirsevimab) are contraindicated or insufficient

External Review in Washington

If Humana upholds their denial after internal appeal, Washington residents can request external review through an Independent Review Organization (IRO).

Washington's External Review Process

Timeline: You have 180 days from Humana's final denial to request external review. The IRO must issue a decision within 30 days (72 hours for expedited cases).

How to Request:

  1. Contact the Washington Office of Insurance Commissioner at 1-800-562-6900
  2. Submit your external review request with all appeal documentation
  3. The OIC assigns an independent medical specialist to review your case

Required Documentation:

  • All correspondence with Humana
  • Complete medical records
  • Specialist recommendations
  • Evidence of medical necessity

The IRO's decision is binding on Humana—if they overturn the denial, Humana must provide coverage.

Medical Necessity Letter Template

Your pediatrician should customize this template based on your child's specific conditions:

TO: Humana Prior Authorization Department
FROM: [Pediatrician name, credentials, NPI]
RE: Medical Necessity for Synagis (palivizumab) - Patient [Name], DOB [Date]

Clinical History:
[Child's name] is a [age] month old infant born at [gestational age] weeks with [primary diagnosis]. Current medical conditions include [list all relevant diagnoses with ICD-10 codes].

High-Risk Criteria Met:
☐ Prematurity ≤35 weeks gestation, currently <6 months old at RSV season start
☐ Chronic lung disease requiring ongoing medical therapy
☐ Hemodynamically significant congenital heart disease
☐ Other qualifying condition: [specify]

Current Medical Management:
Patient requires ongoing [oxygen therapy/bronchodilators/cardiac medications] as documented in recent [cardiology/pulmonology] consultation dated [date].

Medical Necessity Justification:
Based on [patient's] underlying conditions and current medical status, they are at extremely high risk for severe RSV lower respiratory tract disease. Synagis prophylaxis is medically necessary per American Academy of Pediatrics guidelines and supported by clinical evidence showing significant reduction in RSV hospitalization rates in high-risk infants.

Requested Treatment:
Synagis 15 mg/kg intramuscularly monthly for up to 5 doses during the 2024-2025 RSV season.

Provider Attestation:
I certify that the above information is accurate and that Synagis is medically necessary for this patient's care.

[Signature, Date]

Tracking Your Appeal

Maintain detailed records throughout the appeals process:

Appeal Log Template:

  • Date submitted: ___________
  • Method (fax/online/mail): ___________
  • Confirmation number: ___________
  • Expected response date: ___________
  • Follow-up call scheduled: ___________
  • Decision received: ___________
  • Next steps: ___________

Key Contacts:

When Appeals Fail: Next Steps

If both internal and external appeals are unsuccessful, consider these alternatives:

Manufacturer Support:

Alternative Funding:

  • State pharmaceutical assistance programs
  • Nonprofit foundations supporting rare disease medications
  • Hospital charity care programs

Policy Alternatives:

  • Review other RSV prevention strategies with your pediatrician
  • Consider switching to a different Humana plan during open enrollment if formulary coverage differs

Legal Options:

  • Consult with healthcare attorneys specializing in insurance denials
  • File complaints with Washington's Office of Insurance Commissioner

At Counterforce Health, we help families navigate complex insurance appeals by analyzing denial letters, identifying the specific denial basis, and drafting targeted rebuttals with the right clinical evidence. Our platform streamlines the appeals process for both families and healthcare providers, turning insurance denials into successful approvals through evidence-backed advocacy.

FAQ

How long does Humana prior authorization take for Synagis in Washington?
Standard decisions take up to 30 days for medical coverage, 7 days for Part D drug coverage. Expedited reviews (for urgent cases) must be completed within 72 hours.

What if Synagis is not on Humana's formulary?
You can request a formulary exception with supporting medical documentation. Your pediatrician must demonstrate medical necessity and explain why formulary alternatives are inappropriate.

Can I request an expedited appeal in Washington?
Yes, if waiting for standard appeal timelines could seriously jeopardize your child's health. Both Humana and Washington's external review process offer expedited options with faster decision timelines.

Does Washington have special protections for pediatric drug denials?
Washington provides strong consumer protections through the Office of Insurance Commissioner, including free advocacy services and binding external review decisions. The state requires clear appeal procedures and consumer notification of rights.

What happens if I miss the appeal deadline?
Missing the 65-day internal appeal deadline may require starting a new prior authorization request. Contact the Washington OIC immediately for guidance—they may help identify alternative options or exceptions.

How much does Synagis cost without insurance in Washington?
Synagis costs approximately $1,821 per 50mg vial based on state wholesale acquisition cost data. Most children require 5 monthly doses, making the full course over $9,000 without coverage.

From our advocates: We've seen many Washington families successfully overturn Synagis denials by ensuring their pediatrician includes specific weight-based dosing calculations and recent specialist consultation notes in the medical necessity letter. The key is demonstrating ongoing medical management of the underlying condition—not just the historical diagnosis. This approach has proven effective in peer-to-peer reviews with Humana's medical directors.

Sources & Further Reading

Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. For personalized assistance with Humana appeals in Washington, contact the Office of Insurance Commissioner at 1-800-562-6900 or visit Counterforce Health for professional advocacy support.

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