Anti-virals denials in California external review
In the California DMHC record, independent physician reviewers decided 1,351 published external-review cases involving Anti-viralsand overturned the plan’s denial in 81.4%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Conditions behind Anti-virals denials
| Category | Decisions | Overturned |
|---|---|---|
| Hepatitis | 1,282 | 83.4% |
| AIDS HIV | 13 | 61.5% |
| Viral Infection | 9 | 33.3% |
| RSV | 6 | 66.7% |
| Cirrhosis | 3 | 66.7% |
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. | 1,333 | 81.9% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 18 | 44.4% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret for treatment of the enrollee’s chronic hepatitis C virus (HCV), genotype 1a. 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 recommend that all patients should be treated, regardless of fibrosis stage. As ultrasound elastography showed a lack of cirrhosis, thus this patient should be treated as a non-cirrhotic patient. The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Mavyret.
Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus (HCV). Findings: The physician reviewer found that per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment guidelines, there is only one treatment option for this patient in whom previous sofosbuvir plus ribavirin with or without peginterferon treatment has failed, and has no cirrhosis. “Daily fixed-dose combination of ledipavir (90 mg)/sofosbuvir (400 mg) with weight-based ribavirin for 12 weeks is recommended for patients without cirrhosis” is recommended as a Class IIb, Level C rating. AASLD/IDSA states “To date, clinical experience and trial data on the retreatment of such patients are very limited.
Where the denial was upheld
A 48-year-old male enrollee has requested for an additional 12 weeks of Pegasys and ribavirin for treatment of his hepatitis C virus. Findings: The physician reviewer found that the current approved treatment for hepatitis C is pegylated interferon (Pegasys) plus ribavirin for a total of 48 weeks in genotype-1 patients. Some studies have suggested that a longer treatment period may be warranted in those patients who have a late documented viral clearance while on therapy. Currently, a 12-week time point is used to determine the presence of an early viral response (EVR); however, many studies indicate that a 4-week point may also be useful in predicting a response to 48 weeks of therapy.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intramuscular (IM) amino acids methionine, proline, and cystine; placement in a treatment program for chronic Epstein-Barr virus (EBV) using lysine, anti-virals, and rest; and paracervical prolotherapy with neck tracking and physical therapy. Per the current evidence-based peer-reviewed medical literature, treatment with intramuscular (IM) amino acids and prolotherapy are not recommended for patients with fibromyalgia, spine pain, Ehlers-Danlos syndrome, or any of the patient’s listed diagnoses in the medical records.
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 treatment 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 Anti-virals, 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