Zepatier denials in California external review
In the California DMHC record, independent physician reviewers decided 110 published external-review cases involving Zepatierand overturned the plan’s denial in 84.5%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
By condition
| Condition | Decisions | Overturned |
|---|---|---|
| Hepatitis C | 49 | 85.7% |
| Hepatitis C Virus | 36 | 80.6% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50/100 mg one tablet by mouth for 16 weeks and Ribasphere 200 mg three tablets by mouth every morning and two tablets every evening for 16 weeks for treatment of the enrollee’s hepatitis C virus. Findings: The physician reviewer found that 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. This recommendation applies to all patients, regardless of fibrosis stage.
Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Zepatier 50/100 for 12 weeks for treatment of the enrollee’s chronic hepatitis C virus (HCV) genotype 1a. Findings: The physician reviewer found that 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 recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naïve genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: An enrollee has requested Zepatier and ribavirin for treatment of his hepatitis C virus. Findings: The physician reviewer found that according to the 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 guidelines, patients with HIV co-infection are high priority for treatment.
Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for Zepatier 50-100 mg tablets for 12 weeks for treatment of the enrollee’s hepatitis C. 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 recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier with ribavirin for 16 weeks when NS5A resistance is present.
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 Zepatier, 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