Big Break for Little Boy

A little boy's health could depend on a high priced drug.

Two-year old Anthony Mainini has a heart defect called critical coarctation of the aorta. It's when the aorta, the body's major blood vessel, which moves blood thru the heart, is too narrow. Anthony has already undergone four heart procedures for this problem and will soon undergo another one.

His Long Island parents are just trying to keep him happy and healthy until then and one of the ways they do that is by taking him to get a Synagis shot during the winter. The monthly shot protects Anthony from RSV, a respiratory virus that could have serious consequences for a child with a heart defect.

The problem being now that Anthony is two years old, his insurance company, Blue Cross / Blue Shield of Texas, stopped paying for the shots. Each shot has a price tag of $4,200 each. Their criteria stipulates that their coverage stops when a child turns 2.

Even when Anthony's pediatrician wrote BCBSTX a letter requesting that Anthony still needs the shots, they were denied. So Anthony's parents have been borrowing the money from family members to pay for the shot to help keep Anthony healthy.

Out of frustration, they called Help Me Howard and we contacted BCBSTX to get more information. It was at this point that Blue Cross / Blue Shield of Texas decided to reverse their decision and now cover Anthony's shots:

Statement from Blue Cross / Blue Shield of Texas:

"A pre-service determination submitted by Mr. Anthony Mainini was not initially approved by BCBSTX in November 2008, due to the age of the patient, which limited coverage based on our guidelines. Our policy specifically states that the drug requested is covered for children age 2 and younger. However, additional medical/clinical information came to our attention when the decision was appealed which caused BCBSTX to reverse the decision and cover the drug requested. Mr. Anthony Mainini submitted three claims for this drug to BCBSTX in mid-January and all three of these claims have now been processed. We apologize to the member for the delays that he experienced throughout the process of receiving the necessary approvals and guidance."

These days you may have to take on your insurance company if you are denied coverage, but there are several ways you can help your case.

Remember, that even if you are denied the first time, you can appeal and most insurance companies give you 1-2 chances to appeal your case.

Understand your policy. Review it on a regular basis, make sure you understand exactly what is covered and what is not. If you have questions call your insurance company and have them explain.

Be organized--have all your paperwork in order, take detailed notes of your interactions during the process.

Save everything; receipts, reports, etc. Keep a detailed folder with all of your medical paperwork.

And if you feel you still need help, contact your state's Department of Insurance (in some states known as the Department of Managed Care). Every state has different ways of assisting consumers with health insurance appeals. The Kaiser Family Foundation provides information on every state's health care rules.