Chronic Hepatitis C Genotype 1a: when insurers say no, reviewers often say yes
In 12 published external-review decisions involving chronic hepatitis c genotype 1a, independent physician reviewers overturned the insurer’s denial 91.7% of the time.
Most-fought treatments for chronic hepatitis c genotype 1a
| Category | Decisions | Overturned |
|---|---|---|
| Mavyret | 10 | 90% |
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret 100 mg-40 mg, three tablets daily for eight weeks. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. This applies to all patients, regardless of fibrosis. The guidelines recommend that non-cirrhotic treatment-naïve genotype 1a patients should be treated with Mavyret three tablets daily for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S.
Nature of Statutory Criteria/Case Summary: A 40-year-old female enrollee has requested authorization and coverage for Mavyret 100-40 mg, three tablets daily, for eight weeks. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. The guidelines recommend that non-cirrhotic treatment naïve genotype 1a patients should be treated with Mavyret three tablets daily for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Mavyret for 12 weeks. Findings: The physician reviewer found that according to the recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1a patients should be treated with Mavyret for eight weeks. These recommendations are based on multiple randomized clinical trials. Additionally, the medication is U.S.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for chronic hepatitis c genotype 1a was denied, the published record says the denial is worth fighting.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY