Hepatitis C denials in California external review
In the California DMHC record, independent physician reviewers decided 487 published external-review cases involving hepatitis cand overturned the plan’s denial in 78.9%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for hepatitis c
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. | 473 | 79.3% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 14 | 64.3% |
What the reviewers wrote
Where the denial was overturned
This patient is a 43-year-old female with chronic active hepatitis C, genotype 1a who was treated with PEG Intron and ribavirin in 2004, and relapsed after the completion of therapy. She has no history of suicide or depression. The patient’s last liver panel revealed normal bilirubin, AST, ALT, total protein, albumin, total bilirubin, PT and INR. The HCV-PCR in December 2005 was 21,099,000 Iu/ml. Her liver ultrasound revealed mild hepatic steatosis without focal lesions. When last evaluated by her hepatologist, the patient was doing well and showed no signs or symptoms of decompensated liver disease. She had no symptoms of mental confusion or forgetfulness. The patient has requested authorization for retreatment with Infergen and ribavirin therapy.
Nature of Statutory Criteria/Case Summary: An female enrollee has requested authorization and coverage for Zepatier 50 -100 mg for treatment of the enrollee’s hepatitis C. Findings: The physician reviewer found that 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 should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines state that patients with cirrhosis are high priority for treatment, and that cirrhotic, treatment-naive, genotype 1 patients should be treated with Harvoni for 12 weeks or Zepatier for 12 weeks. Both medications are U.S.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for treatment of the enrollee’s hepatitis C. Findings: The physician reviewer found that 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 should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier (with ribavirin when NS5A resistance is found) and Epclusa. However, although the U.S.
Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for Zepatier 50-100 mg tablets for 12 weeks for treatment of the enrollee’s hepatitis C. Findings: The physician reviewer found that 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 should be treated, except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier with ribavirin for 16 weeks when NS5A resistance is present.
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 hepatitis c, 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