Hepatitis C Virus Genotype 3: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for treatment of the enrollee’s chronic hepatitis C virus genotype 3. 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 regardless of fibrosis stage should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. Although, a possible enlarged lymph node was seen on ultrasound, there is no established medical condition in this case that limits life expectancy to less than one year.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Epclusa 400-100 mg tablets for 12 weeks. Findings: The records provided for review document that this patient has a history of hepatitis C virus, genotype 3. The provider has recommended treatment with Epclusa for 12 weeks based on the patient’s genotype and treatment naïve status. 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. The guidelines noted that these recommendations apply in all cases, regardless of fibrosis stage.

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 hepatitis c virus genotype 3 was denied, the published record says the denial is worth fighting.