Diagnosis: tracheomalacia and chronic lung disease of prematurity with bronchopulmonary dysplasia (BPD).

Treatment: Synagis 50MG/0.5ML IM (intramuscular)

The insurer is denied coverage for Synagis 50MG/0.5ML IM

The denial is upheld.

This male patient has a history of developmental delay, premature infant around 20 weeks gestation, and severe bronchopulmonary dysplasia (BPD).

Although the patient was born as an extreme premature infant with a diagnosis of BPD the medical record indicates that he has been medically stable off oxygen and pulmonary medications. There is no record of need for hospitalization or ER visits in the past 9 months despite exposure to the Covid 19 virus. The medical record does not support the need for a second series of Synagis injections.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the Synagis 50MG/0.5ML IM is upheld. The medical necessity is not substantiated.