Denial of Treatment AGAIN !

[tmf2]

I  am at wits end and in desperate need of help with working with Allegiance/\Cigna which continually denies the medication to treat my life threatening illness. We have Allegiance\Cigna  managing the employee self funded policy as my wife works for the county\ Allegiance \ Cigna approved Harvoni for a 12 week treatment after a liver biopsy showing I had F4 Cirrhosis on March 3, 2015  my gastro never suggested testing for resistance-associated variants ( RAVs)  prior to requesting the medication Harvoni failed.I suggested to my gastro a RAV test he agreed and I was positive for RAVs. . I determined it was time to seek out a liver specialists.at a Liver Ctr.

My new Dr a Herpetologist whom is very active with research and treatment stated a new drug that specifically addresses  RAVS will be approved in July 2016 called Epclusa and he would prescribe that immediately on  FDA approval due to my urgent medical condition, Prescription was sent in July for pre-approval and was denied Aug 1st .  I  contacted  Hospital who stated they  forwarded an appeal but were getting the run-around and didn’t understand why, given the dire condition of my liver. I called Allegiance \ Cigna on October 17th inquiring why no decision on the appeal filed in August given a thirty day decision deadline had expired,.they stated no appeal was filed.  I contacted the Liver Ctr and they said they filed but Allegiance \ Cigna  claimed they could not locate an appeal and requested the Center send another appeal, the ctr requested it be urgent  due to my condition and 21 pages were sent Oct 19th  Allegiance \ Cigna denied that request.

 November 4 2016 I received  a letter for Allegiance\ Cigna which stated they were upholding the original decision of denying treatment. Their basis for denial is having  prior treatment with Harvoni which failed and they would not approve if any prior treatment with a NS5A  inhibitor was used. .They also do not see my treatment as a medical necessity.Allegiance \ Cigna enclosed a form if I wish to appeal via their internal  IRO program which they claim is a independent review program not connected to Cigna although the address is  Cigna National Appeals Organization  located in Chattanooga, TN. I don't know how objective that appeal would be.



Dennis   

[gnatcatcher]

Dennis, based on other threads on these forums, those in the know would recommend you contact the Patient Advocate Foundation's Hepatitis C CareLine (800-532-5274 or www.hepatitisc.pafcareline.org) and even specifically ask for Brendan Bietry. He and his agency have worked wonders for others here.

Gnatty

[Mugwump]

Gilead will also listen to appeals from those who are refused treatment by their insurance corporations. I just cannot find the American number and the Gilead Canadian phone number is not the one you want. Not that Gilead is a sainted organization by any stretch but they do help some people get treated.

I think there might be a possibility of getting co-pay assistance from them with the new multi variant meds.  Either that or they will put a fork in your insurance company and scare them into approval.

Most likely your insurance is just stalling to get better pricing from Gilead because they have deals with other drug companies and they want to save as much on their drug payout liabilities as possible.

This is the problem with having the bean counters making the clinical decisions about health care. They will stall and even lie about things to save dollars and worse get away with it.

Either way I hope this ridiculous situation with the health care insurers and drug companies is resolved positively for you asap.

Eric
 

[Lynn K]

Here is some info to contact Gilead

http://www.hepchope.com/about-hep-c?gclid=Cj0KEQiA6_TBBRDInaPjhcelt5oBEiQApPeTFwBGe7bZqT46xBS1ugqExcGBpkKMVtJt50_eyP1NKfEaAqLX8P8HAQ&gclsrc=aw.ds

WE’RE HERE TO HELP.

Call 844-9-HEPCHOPE to speak with a Hep C Educator.

http://www.hepchope.com/treating-hep-c/helpful-resources

Don't give up there are others here who have appealed successfully.

I believe after 3 denials you can appeal to your state insurance commissioner

Best of luck to you

[lporterrn]

Ditto on all of the above. Also: call Help4Hep and 877 Help 4 Hep (877 435 7443). In case you need documentation, here is a link to current recommendations: http://www.hcvguidelines.org/full-report/retreatment-persons-whom-prior-therapy-has-failed

[hguy]

I went through the the same thing for years. The out for the insurance is the term "self management". After being injured on the job and being on comp I lost my insurance and became medicaid eligible. Guess what. Medicaid is paying for Harvoni. Very unfair but at least im getting treatment.I also had same problem with pegified interferon,ribavarin and victrellous treatment four years ago but I qualified for free medicine because I wasnt earning as much then but that treatment didnt take. Call everybody. Call the drug makers and your local congressman. Very unfair and fustrating. Best of luck to you. I hope you dont have to suffer an injury like me and not be able to work before you get treatment.                49 genome type 1a male contracted in the 80s from IV drug use(clean for 22 years).   Again I know what you are going through and good luck to you.                                                                             

[lporterrn]

Just a general note for everyone. Things change. Closed doors and an inability to get insurance approval for treatment more than a year ago doesn't mean you'll have the same experience now. Keep trying.

[tmf2]

Finally.............Finally...........Finally approved (after 3 denials)  for Epclusa/Riba for 24 weeks ! What a fight to get approved after the 12 week Harvoni failure. Funny thing I was clear on Harvoni midway through.These Insurance companies just do not want to retreat. Just imagine if they felt that way about reoccurring cancer with patients. We shouldn't have to go through all this to get treated .

Started Dose 1 this morning!


Dennis

[Lynn K]

Alright congrats Dennis!

Any details on the process you used or was it all behind the scenes? 

[andrew90]

WOOOOHOOOOOOOOOOOOOOOO

[gnatcatcher]

Glad to hear the good news.

Dennis, please let us know what finally worked in your case. It could help us help others down the road who are having similar difficulties. Thanks.

Gnatty

[tmf2]

I wrote a letter to the State Auditors Dept of Insurance complaining about the denial of treatment and also my hepatologist also called the Insurance company supporting my claim. My doctors office houndied them and was very pro active with the process. Also be sure to check the new guidelines as they have just changed. My original situation called for 12 wks Epclusa and is now 24 with Riba. They will deny based on the prior guidelines without notifying you specifically  why ie ( Not medically necessary) the generic response. I found the support in these forums invaluable and shout out a thanks !! Now I hope the Riba is not too bad as Harvoni was a cake walk for me.

Dennis

[lporterrn]

Christmas came early for you. Fantastic. We'll help you through the ribavirin. Many of us survived 48 weeks (or more) and picked up survival tips.

[tmf2]

Thanks lporterrn.....I  weight train 3 days a week and jog 3 days a week with Sun off and also eat a proper healthy diet.........heck haven't seen a french fry in 4 years !  So hopefully this will fall in my favour.


Dennis