Hepatitis C Virus Genotype 3 denials in California external review
In the California DMHC record, independent physician reviewers decided 12 published external-review cases involving hepatitis c virus genotype 3and overturned the plan’s denial in 100%. 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 3
What the reviewers wrote
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.
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 3, 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