Hepatitis C Virus Genotype 2b denials in California external review
In the California DMHC record, independent physician reviewers decided 17 published external-review cases involving hepatitis c virus genotype 2band overturned the plan’s denial in 82.4%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for hepatitis c virus genotype 2b
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret 100 mg-40 mg tablets for eight weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee’s hepatitis C virus, genotype 2b.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 2 patients should be treated with Mavyret for eight weeks.
Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and ribavirin for treatment of her hepatitis C virus genotype 2b. 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 applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naïve genotype 2 patients should be treated with Sovaldi and ribavirin for 12 weeks. These guideline 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 Sovaldi and ribavirin for treatment of the enrollee’s chronic hepatitis C virus genotype 1a and 2b. 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 treatment guideline applies regardless of fibrosis stage or viral load. Per guidelines, when multiple genotypes are present, therapy should be chosen to maximize efficacy against each genotype. In this case, the patient was already treated with Sovaldi and Ribapak, as Sovaldi is a component of the Harvoni that was provided.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Sovaldi 400 mg once per day and Ribasphere 600 mg twice daily for 12 weeks for treatment of the enrollee’s chronic hepatitis C virus (HCV) genotype 2b. .Findings: The physician reviewer found that According to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment.
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 virus genotype 2b, 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