Author Topic: Denied (Read 22820 times)

missa1123 · « **on:** August 27, 2015, 04:49:24 pm »

So I got my first denial letter today from Highmark (BCBS) it says I was denied "because this medication or combination is not covered for members with documented METAVIR score. Documentation does not demonstrate that member has EGFR grwater than or equal to 30 ML/MIN/1.73 M2"
Ok what does this all mean? Any info would be greatly appreciated.

missa1123 · « **Reply #1 on:** August 27, 2015, 04:50:13 pm »

My Dr. Was trying to get me Harvoni

gnatcatcher · « **Reply #2 on:** August 27, 2015, 06:30:59 pm »

EGFR means Estimated Glomerular Filtration Rate. It is a test of kidney function. Gilead didn't include people with EGFRs under 30 when it ran its clinical trials, so it cannot guarantee that Harvoni is safe for them. (My hepatologist feels sure that it IS safe for them, but this provides an out for insurance companies.)

Your doctor will need to have you take a blood test to determine your EGFR. Unless you have very, very serious kidney disease, you will then have a result that is greater than or equal to 30 and your documentation with this additional information can be submitted to BCBS.

Else · « **Reply #3 on:** August 27, 2015, 07:00:26 pm »

Quote from: missa1123 on August 27, 2015, 04:49:24 pm

So I got my first denial letter today from Highmark (BCBS) it says I was denied "because this medication or combination is not covered for members with documented METAVIR score.

What Gnat said is correct re: - it sounds like they did not receive a required lab documenting your EGFR.

But it also sounds like they are denying based on your Metavir score. That's the degree of fibrosis your liver has. Values range from F0 to F4 which is cirrhosis. This is usually established via a Fibroscan test, a Fibrosure blood test or a liver biopsy which is still considered the gold standard but not required.

Depending on your insurance, they can (try to) require an F3 as a minimum for treatment. My insurance will accept F2.

Else · « **Reply #4 on:** August 29, 2015, 01:21:57 pm »

Hi Missa,

I should have been clearer in my last post. When I said, "depending on your insurance, they can try..." my point was appeal, appeal, and appeal again!

A first denial is often just the first step in obtaining treatment. Best of luck!

yag1064 · « **Reply #5 on:** August 30, 2015, 12:41:28 pm »

Good morning missa1123,
I have had two treatments for Hep C. The first was using Interfurion and Ribavirian in 2007. I was a non respond-er to it and was taken off before the full 48 week treatment was completed. Then in 2014 Solvaldi became available. The cost by itself was $84,000. That is $1000.00 per pill My insurance denied me but I appealed and was given the pills. I was undetectable after 2 weeks and remained undetectable three months after treatment ended. My Hep C returned after six months for reasons I am not sure why. My Dr. wants to put me on Harvoni. That's even more expensive. About $1300.00 per pill. My insurance denied the request. I talked with them and was told that acceptance was determined by need. As the spokeswoman said, if they gave it to everyone, they would go out of business. I am going through my second appeal. It is important your doctor puts together a strong justification document that includes your current liver health, cirrhosis and other conditional evidence. Work closely with your doctor to make sure they summit the strongest case possible and do it in a timely fashion. Hep C is difficult to get rid of regardless of the advertisements on TV lead you to believe. Contact Gilead, the makers of Harvoni, and enroll in their support path program. You may be able to receive the medicine at little or no cost.
Take an active role in your treatment. You are the best advocate. Stay strong and positive. Never give up. You are worth it. This is a great place to be. There are many caring and supportive individuals who are genuine and are fighting themselves in this battle we share.

Remain positive!
Rick

Joe NM · « **Reply #6 on:** September 11, 2015, 03:03:29 pm »

It's good news/bad news: they were telling you you weren't sick enough to warrant treatment yet. The lab results/standards they were citing all come down to this: these numbers have to look worse, if one of these gets high enough/low enough, then we'll decide you're sick enough and go ahead and cover the treatment.

If the prescription was for Harvoni, you might want to talk to your doctor about whether Viekira Pak would be safe for you, as they have a program that can cover the whole cost if your insurance denies you and then also denies an appeal.

BDK · « **Reply #7 on:** September 11, 2015, 05:55:27 pm »

Please appeal. And if denied again, please request an external (independent) medical review. The external reviewers do overturn these denials. Keep trying - it is worth it!

Else · « **Reply #8 on:** September 11, 2015, 06:20:24 pm »

Do not give up! Exhaust the internal appeals processes (and, yes, they are exhausting

). You then have the right to an External Appeal. They can and do overturn denials and your insurance company is bound by their decision.

Your insurance company is counting on you to give up. In my opinion (and happily, my experience

) a gastroenterologist not on your insurance company's payroll is unlikely to decide that treating your Hepatitis C is medically unnecessary.

It's a grind, but hang in there!

drummerman · « **Reply #9 on:** September 13, 2015, 02:15:37 am »

Yep,
they wouldn't approve harvoni for me either. But I have heard of other repeated appeals actually working. And your nurse needs to let insurance know that you have severe joint pain, fatigue, depression, list everything. Sometimes that works.

I was approved for viekira, which is 83,000, but my insurance company cut a deal with abbvie and am getting it for 35,000. Still pretty steep. I have a 25.00 copay. But the way I look at it, I worked a job for 33 years and paid for insurance every month. I'm sure my total paid over the years was well over 35,000.

Like everyone says... appeal, appeal, appeal,.... use the phone too. Sometimes you can wear these people down. I was on the phone everyday for a month...I am not exaggerating. And lost it several times... and asked to speak to supervisors every time.
I truly believe (at least in my case) they were intentionally making it difficult in an attempt to make me give up.... and I almost did. I also had a nurse advocate that said she got me the authorization. She was feisty and I only got her cause my doc was wanting to use her pharmacy (apparently these drugs can't be picked up at the corner drug store), she told me to call her when it was all over and let her know if I cleared. And I will.

I have also heard that walgreens have these nurse advocated too. And can be pretty persuasive.

dm

rifkhaz · « **Reply #10 on:** September 15, 2015, 03:31:20 am »

I was diagnosed with Hep C about ten years ago. I have had this in my blood since 20 years now because of a blood transfusion. I was treated twice with no success prior to Harvoni coming into the market. My point is basically this. Once you have cirrhosis of the liver your liver never really heals itself to how it was before you got hep C.

Product advertisement and solicitations (including links); banners; and clinical trial, study or survey participation—is strictly prohibited by forums members unless permission has been secured from the Hep Forum Moderators. This post has been edited to remove such information. - Hep Forum Moderators

drummerman · « **Reply #11 on:** September 15, 2015, 07:12:45 am »

I looked at all the herbal remedies and used a lot supplements , etc. , read alot about chinese herbs and diet, etc. Read many books, look at many websites.

I took sups, I took herbs.

While I do believe there are many herbs that will slow down hcv damage progression , I eventually came to the conclusion that there is no such thing as a herbal remedy that will cure hcv.

And I certainly would not take herbs while on harvoni.

viral load means nothing as well, it goes up and down daily.

If you clear , it is because of the harvoni, not herbs.

dm

Joe NM · « **Reply #12 on:** September 15, 2015, 02:06:54 pm »

Please post a link/information/name of that herbal treatment. Kind of fishy not to just post it outright...I'm skeptical but super curious what it is, if it can help liver function. Granted, it would not lead to clearing the virus, and I doubt many studies have been done on it in terms of what other effects it could have on the body/how consistent the herbs are since it's unregulated and you can't tell for sure what's in the supplement. And don't take it at the same time as Harvoni, absolutely!

In terms of viral load, it's important to know that a high load vs. low doesn't tell you whether or not liver damage is occurring. Low can cause just as much damage as high, and there's no real correlation. From the Hepatitis C New Drug Research and Liver Health web site: "Viral load is the amount of virus present in the bloodstream. It is expressed as the amount of viral genetic material (RNA) per milliliter of blood. High viral load is often seen in people who have been infected for a long time. People who acquired HCV because of a needle also tend to have high viral load. Viral load is not related to the amount of liver damage, or to how sick someone is."
http://hepatitiscnewdrugresearch.com/hcv-viral-load-test.html

drummerman · « **Reply #13 on:** September 15, 2015, 10:07:36 pm »

I've seen this before during round 1 of tx. Its all a scam. Don't buy into it.
The reason he is saying he is taking it with harvoni is because he sees so many on here on harvoni , he wants to sell it to them as well.

Who in their right mind would take an herbal remedy with harvoni?? Makes no sense. No herb(s) can cure hcv. It is not possible.

In my long search I only found one product that could slow down liver damage from hcv (but it will not clear the virus) and it was not herbal and it was expensive. I took it as long as I could afford it and truly believe it slowed down my liver damage (look at my signature)... but like I said, I had to quit... couldn't afford it.

But if you are having problems getting tx approval, you might look into the product.

check out their web site at:
#####

I just modified this, cause I saw the rule that said you can't post links.

Could this be "snake oil" as I believe the previous poster is. I guess it could be , but I read every bit of their research and it all seemed to make sense to me.

dm

drummerman · « **Reply #14 on:** September 15, 2015, 10:12:29 pm »

Quote from: Joe NM on September 15, 2015, 02:06:54 pm

Please post a link/information/name of that herbal treatment. Kind of fishy not to just post it outright...I'm skeptical but super curious what it is, if it can help liver function. Granted, it would not lead to clearing the virus, and I doubt many studies have been done on it in terms of what other effects it could have on the body/how consistent the herbs are since it's unregulated and you can't tell for sure what's in the supplement. And don't take it at the same time as Harvoni, absolutely!

In terms of viral load, it's important to know that a high load vs. low doesn't tell you whether or not liver damage is occurring. Low can cause just as much damage as high, and there's no real correlation. From the Hepatitis C New Drug Research and Liver Health web site: "Viral load is the amount of virus present in the bloodstream. It is expressed as the amount of viral genetic material (RNA) per milliliter of blood. High viral load is often seen in people who have been infected for a long time. People who acquired HCV because of a needle also tend to have high viral load. Viral load is not related to the amount of liver damage, or to how sick someone is."
http://hepatitiscnewdrugresearch.com/hcv-viral-load-test.html

Yeah, rifkhaz post the link to this miracle cure. Let's see it.

Rosie13 · « **Reply #15 on:** September 15, 2015, 10:26:07 pm »

Agree with drummerman...very dangerous to do anything herbal with Harvoni.Read your bottle ...When I am done with my treatment I am going to go back to my herbal ways but now I have my miracle working!

slats1056 · « **Reply #16 on:** September 15, 2015, 11:32:10 pm »

rifkhaz, Just curious, any labs to back up statements. Prior to the herbal and current? I have had the Dragon on My back since about '73 or '74 and have done My share of herbals and what not. Never once heard of one that guaranteed clearing the virus to undetected status. My blood work over the Years have shown the viral load all over the charts but have for the most part kept it in check. Never had any dealings with this wonder herbal treatment of which You speak, I would like to know more. I hope this is not just a wild goose chase to promote a sales pitch.

Scoutdoy · « **Reply #17 on:** September 16, 2015, 12:49:47 am »

Tommy,,,,,that post of his reads as if it is totally scripted as a sales pitch, and I hope people who are desperately trying to get medication or who are on harvoni now understand how dangerous it could be to mix herbs and these new meds. This sounds like a scripted testimonial and that is no good. I hope I am wrong but I don't think so

Scout

Else · « **Reply #18 on:** September 16, 2015, 01:15:42 am »

A miracle herbal remedy for Hep C not worth posting specifics about? And yet here you are, Rif. Predatory much?

Scoutdoy · « **Reply #19 on:** September 16, 2015, 01:27:35 am »

Did you notice this person has only had 2 posts and wants people to contact him via email? Ugggggg

Scout

Lynn K · « **Reply #20 on:** September 16, 2015, 01:54:15 am »

Magic beans.....

Scoutdoy · « **Reply #21 on:** September 16, 2015, 02:15:03 am »

What's disturbing me Lynn is that a person on here who has 2 posts is offering a "cure" and saying "email me for the magic beans" and when some people are on here desperately looking for a cure to this crappy disease they are vulnerable. Trying to get approved for medication is stressful enough.... Uggggg

Scout

Lynn K · « **Reply #22 on:** September 16, 2015, 02:18:17 am »

I had a longer post but I just went with that for now. I don't have all the keys to the machinery here.

slats1056 · « **Reply #23 on:** September 16, 2015, 08:42:47 am »

Scout, Lynn, & Else, I agree with all of You guys , willing to give Him the benefit of the doubt for the time being. Time will tell. Give a Man enough rope & he will eventually hang himself. I am hoping for His sake that all is above board. I believe in the transparency here on the forums. Definitely not a place for sales spiels and/hoaxes. Magic beans indeed, But let us hope the truth comes out.

slats1056 · « **Reply #24 on:** September 16, 2015, 05:48:18 pm »

DO WHAT?

?? RADAR SAYS DANGER ALERT. TARGET LOCKED. DRUMMERMAN?

YOU ARE IN TURKEY?

drummerman · « **Reply #25 on:** September 16, 2015, 06:51:55 pm »

Its a joke... directed at herbal hcv cure scam guy that posted above.

Sorry,... Had no idea anyone would take this seriously.

I totally apologize.

I thought it was pretty funny though.

dm

slats1056 · « **Reply #26 on:** September 16, 2015, 07:06:17 pm »

DM , Good one Dude. Totally sucked that one in hook , line, and sinker. In My line of work a lot of scams get started just like that. Unfortunately , the company has been taken for a ride by some of our greedy & gullible salesmen!!! I apologize for the knee jerk reaction. It's just force of habit. Sure as HELL don't want anyone to get sucked in, which is what all of this looks like. Again good one dude. I can feel the hook all the way down in My stomach I swallowed so hard. LMFOA! Extremely funny !

drummerman · « **Reply #27 on:** September 16, 2015, 07:25:25 pm »

Quote from: slats1056 on September 16, 2015, 07:06:17 pm

DM , Good one Dude. Totally sucked that one in hook , line, and sinker. In My line of work a lot of scams get started just like that. Unfortunately , the company has been taken for a ride by some of our greedy & gullible salesmen!!! I apologize for the knee jerk reaction. It's just force of habit. Sure as HELL don't want anyone to get sucked in, which is what all of this looks like. Again good one dude. I can feel the hook all the way down in My stomach I swallowed so hard. LMFOA! Extremely funny !

I am so sorry... guess I shoulda made it more apparent.

Anyway, I'm fine and not in Turkey, but you can send me money if you like.

dm

Mike · « **Reply #28 on:** September 16, 2015, 07:31:47 pm »

Just a quick reminder: We don't allow solicitations of any type in this forum. Please report any suspicious posts, links and so on to the moderators for proper handling.

Thanks, Mike
Forum Moderator

slats1056 · « **Reply #29 on:** September 16, 2015, 08:23:18 pm »

DM , No apology needed. That one was all on Me! LOL, Hope I didn't start any crap. I had a brain fart there, Forgot this is on the forum & not the e-mail server at work. My bad! A couple of us were winding up at work & I was doing a last minute check before logging off to go Home and I over reacted with out thinking.

drummerman · « **Reply #30 on:** September 16, 2015, 09:07:29 pm »

Quote from: slats1056 on September 16, 2015, 08:23:18 pm

DM , No apology needed. That one was all on Me! LOL, Hope I didn't start any crap. I had a brain fart there, Forgot this is on the forum & not the e-mail server at work. My bad! A couple of us were winding up at work & I was doing a last minute check before logging off to go Home and I over reacted with out thinking.

No worries man. It was bad judgement on my part.

dm

Onefluover · « **Reply #31 on:** September 18, 2015, 10:37:48 pm »

Quote from: rifkhaz on September 15, 2015, 03:31:20 am

I was diagnosed with Hep C about ten years ago. I have had this in my blood since 20 years now because of a blood transfusion. I was treated twice with no success prior to Harvoni coming into the market. My point is basically this. Once you have cirrhosis of the liver your liver never really heals itself to how it was before you got hep C.

Product advertisement and solicitations (including links); banners; and clinical trial, study or survey participation—is strictly prohibited by forums members unless permission has been secured from the Hep Forum Moderators. This post has been edited to remove such information. - Hep Forum Moderators

Yeah... I was on to this the minute it posted. SPAM. I have the highest moderator position in the biggest virus forum there is (though this forum is pretty big too and growing more rapidly). I've suspended the accounts of and or deleted, edited or hidden or counseled I don't know how many hundreds of posts just like this one. But I'm brand new here and so it's not my place really to even comment on this but after you'all have had your say I figured what the heck, I'll throw my $1.02 in... (..inflation).

One thing that caught my eye, aside from the unsolicited and entirely unverifiable "cure", and aside from the common spammer-type user name, is that they mention they were infected 20 years ago via blood transfusion. Hepatitis C, transmitted through blood transfusion has been extremely rare since July 1992 because of the advent of the test to detect it in the blood supply on that date. It was only days after that test became available that my own anti HBS plasma was detected to harbor HCV.

I doubt this mentioned poster is even infected.

Scoutdoy · « **Reply #32 on:** September 18, 2015, 11:01:23 pm »

I agree onefluover 100 %.

Scout

Coach Mike · « **Reply #33 on:** November 08, 2015, 01:23:41 pm »

Hi,
My 3rd denied script for Harvoni is in the "external review" stage right now. Their 45 days will be up next week. We will see. A lot has to do with your insurance company's wording in their criteria for treatment.
I feel I will be denied again and bought my generic harvoni directly from the supplier used by Dr. Freeman of fixhepc in Australia. I am on dose 17. Also, licensed generic harvoni is supposed to be available in India any day now, if not already.
Good luck and get well!
Mike

Rosie13 · « **Reply #34 on:** November 08, 2015, 11:21:41 pm »

Hey coach mike, sorry to hear you are being treated badly by insurance.I have been there too but prevailed in the end.I'm curious how you could buy generic directly.does your Dr.order it?I read the posts from that guy who traveled to India to get Solvaldi.He needed a script from his dr. & had to see another GI dr. In India.

Coach Mike · « **Reply #35 on:** November 08, 2015, 11:31:23 pm »

I asked the India guy, Greg Jeffreys, where the fixhepc buyers club got their meds and ordered them directly from their supplier, Beijing Mesochem. 12 weeks of sof & led(harvoni)-$1916.
Those Aussies have got something going down there!
Mike

Coach Mike · « **Reply #36 on:** November 08, 2015, 11:35:10 pm »

I simply told them I needed them for research. No script required.
Mike

Rosie13 · « **Reply #37 on:** November 09, 2015, 12:16:31 am »

That is some super info!!! Thanks for all the people behind us that can have options when denied!I got an email about generics were here...good luck to you Mike!

Else · « **Reply #38 on:** November 09, 2015, 01:08:30 am »

Mike, I think I've already said this but this is a great thing you are doing!!!

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