Chronic Hepatitis B denials in California external review
In the California DMHC record, independent physician reviewers decided 14 published external-review cases involving chronic hepatitis band overturned the plan’s denial in 78.6%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for chronic hepatitis b
| Category | Decisions | Overturned |
|---|---|---|
| Vemlidy | 11 | 81.8% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 11 | 81.8% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 3 | 66.7% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for a liver fibrosis test. FibroTest (liver fibrosis test) has demonstrated that it reliably determines the presence of advanced fibrosis and cirrhosis in a variety of liver diseases, including hepatitis B. Liver biopsy, by contrast, is invasive, with risks including bleeding and bile duct injury. It is also subject to interoperator variability during interpretation and sampling error. The American Association for the Study of Liver Diseases guidelines for hepatitis B characterize FibroTest as valid for the assessment of liver fibrosis and cirrhosis, and recommend assessment of fibrosis in the diagnostic criteria to characterize hepatitis B and differentiate chronic hepatitis B from immune-tolerant, immune-active, and inactive hepatitis B.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for apolipoprotein testing as a component of a NASH FibroSURE test panel. Medical literatures note that chronic hepatitis B may result in complications of severe liver disease and in cirrhosis. Medical literatures explain that cirrhosis is the final outcome of all chronic liver disease, and that management of cirrhosis requires specific therapy and monitoring for complications such as hepatocellular carcinoma surveillance with ultrasound and alpha-fetoprotein every six months, and monitoring for portal hypertension, esophageal varices, and hepatic encephalopathy. Researchers report that fibrosis blood tests have been validated in chronic hepatitis C and that the diagnostic performance of blood tests in hepatitis B.
Where the denial was upheld
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for a liver fibrosis test. According to the medical records, the patient has chronic hepatitis B. Current American Association for the Study of Liver Diseases and American Gastroenterological Association guidelines recommend transient elastography as the preferred noninvasive modality for fibrosis assessment in chronic hepatitis B.Transient elastography demonstrates superior diagnostic accuracy for advanced fibrosis and cirrhosis in patients with chronic hepatitis B compared with serum-based liver fibrosis testing.
The patient is requesting authorization and coverage for Vemlidy 25 mg tablets.Findings: Guidelines recommend entecavir and tenofovir for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with fewer incidence of side effects such as osteopenia and renal disease. However, the other guidelines also support the safety and efficacy of entecavir for the treatment of hepatitis B, and entecavir is not associated with these adverse effects. This patient does not have a documented contraindication to entecavir.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving chronic hepatitis b, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY