Daklinza denials: what the review data shows
Independent reviewers have decided 59 published cases where an insurer denied Daklinza — and they overturned the insurer 81.4% of the time. A denial for Daklinza is a starting position, not a final answer.
By condition
| Condition | Decisions | Overturned |
|---|---|---|
| Hepatitis C Virus | 29 | 79.3% |
| Hepatitis C | 16 | 87.5% |
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for 12 weeks for treatment of his hepatitis C virus (HCV). 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) “Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons.
Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi, Daklinza and Ribasphere for treatment of his hepatitis C virus. 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 limited life expectancy due to non-liver-related conditions. The guidelines state that patients with cirrhosis are high priority for treatment. The guidelines recommend that cirrhotic patients with genotype 3 hepatitis C who have failed treatment with Sovaldi and ribavirin should be treated with Sovaldi, Daklinza, and ribavirin for 24 weeks if ineligible for peg-interferon.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for a 12 week extension of Sovaldi, Daklinza and ribavirin. 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. However, this patient has started a 12-week course of Sovaldi, Daklinza, and ribavirin.
Nature of Statutory Criteria/Case Summary: An enrollee has requested Daklinza and Sovaldi for treatment of the enrollee’s hepatitis C virus. 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 limited life expectancy due to non-liver-related conditions. Per the guidelines, patients with cirrhosis are high priority for treatment. In cirrhotic treatment-naïve genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 24 weeks.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Daklinzawhen you appeal: reviewers routinely find that denials like yours didn’t hold up.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY