Harvoni - first denial from BC/BS

[jarrudy]

I just got the first denial letter from Blue Cross Blue Shield:

'the diagnosis of Hep C in a patient that responded to prior treatment does not establish medical necessity of this drug. '   

I am Stage 3/4. I did the triple combo therapy last year (after 3 failed attempts of just pega interferon in years past), and I got to non-detect during treatment, until 3 months after, when it returned. My doctor and I have been waiting on this new treatment. I've seen alot of posts on insurance companies on here. Does anyone have any experience with Blue Cross Blue Shield, and a path to approval? The customer service reps I've talked to are all saying that I have to prove it's a 'medical necessity' or that it was not successful. I looked at the BCBS criteria, and this is the statement that worries me:

Previously treated with Hepatitis C therapy not including Sovaldi and Olysio, and was determined to be a non-responder (defined as prior treatment failed: patient was not able to achieve an undetectable viral load during treatment)


Does this mean because I responded, then it came back, that I am not eligible because they consider it 'successful'? Has anyone else dealt with this?

[BattleTheBeast]

Hi Jarrudy,

I think it means exactly what it says, a non-responder means the meds given during the treatment didn't help you but they didn't include S/O combo in your treatment.   

There is the Mysupportpath option, I am not sure calling BCBS will help you at this point. You need to get it resubmitted or appealed and I have no clue how that works. Honestly I have not heard that a stage 3/4 being denied but I am a newbie to all of this.

Did you apply for Harvoni or S/O, perhaps your doctor can try Harvoni if he tried the S/O. I was fortunate that my approval came quickly but not so fortunate with the current side effects however beyond grateful to be getting treatment.

Stay strong and one of the veterans on here will probably offer a lot more advice than I can.  You can also search the forum for keywords like appeal or denial

Don't give up whatever happens, there is a light at the end of the tunnel. For some of us the tunnel is a little longer to crawl through is all.

~Mel~

[Lynn K]

Hi jarrudy

I found your reference do you have caremark as prescription coverage as that is what your quote brought up in my search:

http://www.caremark.com/portal/asset/FEP_Criteria_Harvoni.pdf

As I understand it a relapse is one of the types of failure so to me the wording is awkward to say the least in their statement as that would only include non responders it would not even include relapse and that is ridiculous.

I have similar concerns. I also have BCBS through my job but I have Express Scripts and Accredo for specialty pharmacy. I am gt 1a diagnosed with cirrhosis in Jan 2008. I treated 3 times and was a null responder to interferon based medicines. My doctor just submitted for approval for Harvoni for me today. The reason I am worried I may have problems getting approved is I treated with Sovaldi Olysio and relapsed after 12 weeks post. I should hear more soon let us know how you r appeal goes and I would contact Support path to try to push you prescriber

Good luck
Lynn

[jarrudy]

Thanks for the support guys. I have calls into the doctor, and I'm gathering all the information that I can to figure out the criteria, and what will get an approval. This is also open enrollment season for the next few weeks, and I've heard better things out of United Health Care. May be time to switch. I will post back with any updates or new info.

[Lynn K]

Hi all

Just called express scripts automated line. My request for Harvoni was not approved. Stayed on the line to speak with a representative. The woman reading me the denial could not pronounce any of the med names even had to sound out how to say peg interferon.

Waiting on my denial letter and appeal from my doctors office.

Dang
Lynn

[lporterrn]

Lynn and everyone - If you are up for this, I know someone who is collecting denial letters. Please PM me and I will give you his email.

[art1951]

When I spoke to my doctor he mentioned that he has had to battle with insurance companies and it has taken him up to 6 weeks and 10+ denial letters and responses until he finally gets it authorized.  He told me to be prepared for the 6 weeks but mine went through in 5 days with BCBS. 

BCBS later wrote me a letter to use their recommended pharmacy but when I called them they had not heard of Harvoni and did not have it in their system yet. 

I have been on Harvoni since October 17th.

Hang in there and keep trying.

Art

[lporterrn]

Jarrudy - You didn't say which triple therapy you tried before. If it did not include Sovaldi. then you have a case for Harvoni, and I beleive this denial was a mistake. Between your doc, My Support Path, and you, I feel confident this will get worked out. Keep trying.

If you failed with Sovaldi, this the AbbVie 3 D will be out late December.

[jarrudy]

Hi,
sorry about that, I did not use Sovaldi. It was interferon/ribovarin/telepravir. There is some very murky wording with the non-responder language. My understand is that non-responder is the category, with subcategories of null responder, partial responder, and respond relapser. I was the last one. I talked with a BC/BS pharmacist today, who really didn't know the answer, which was kinda horrifying considering they are making the decision. Messages out to the doc to work with them on the appeal, here's hopin....

[FRED220]

For those of us that failed S & O or stopped because of a medical issue and can not do Riva or Inteferon I would think the only option now is Harvoni. I believe abbvie has Riva, is that correct?

[Lynn K]

My doctor the Director of the Liver Center at Swedish Hospital Seattle said she contacted Gilead about re-treatment of Sovaldi relapse patients her message here:
"I talked about your case (no names) with Gilead and they've retreated sofosbuvir failures with Harvoni and had cures. We did agree that 24 weeks is probably advisable."

Also as Fred said I have cirrhosis and low platelets so Ribavirin is not a good idea . The effectiveness of the AbbVie 3D with Ribavirin 24 weeks for patients wit cirrhosis previous null responders results on the Turquoise II trial were about 92.9% which does not beat Harvoni 24 week with the same group of 99%. I treated multiple times with different interferon combinations why can't I treat with a different Sovaldi regime? And since when do prescription drug insurance providers make life and death decisions in conflict t with your doctors decisions?

[FRED220]

On Nov 17th I will be in a Medical Center that a Gilead Rep will be there along with several Doctors to answer all questions of future patients. I have my list ready and I am willing to ask them questions from all of you that you would like for me to ask. Please feel free to send them to me. Also, I will speak to the coordinator that sends all the reports to the carriers for approval and I have questions for her too. The last time I spoke to a nurse from UM Hospital I was told that BCBS was not approving  Harvoni unless the Doctor wrote a letter that is was medically necessary to take Harvoni and that at this time there was nothing else for the patient to take, the patient must have cirrhosis and unable to take Riva or Interferon.She also indicated that its very important for the Doctor to make clear the urgency for the treatment.     

[Lynn K]

Hi Fred

I probably have essentially the same questions as you how to get Harvoni as a genotype 1 with cirrhosis, prior null responder, who relapsed on Sovaldi Olysio my insurance is BCBS/Express Scripts through my employer.

I will be looking forward to your answers from your meeting.

Best of luck to you
Lynn

[jarrudy]

Hi all,
Update: Heard back from the doctor's office, and they have a whole team working on this very thing. they have already submitted more information, and are prepared to keep going. Considering we have only a few weeks for open enrollment, I'm happy to see they are on it. They might also have info. on the insurance companies that are being the most reasonable. I will post here once I know. Have to say, going to a hepatology dept. at a research hospital seems to have some perks. A whole team vs one overworked admin trying to do it all. No guarantees yet, but looking hopeful.

[towardhealth]

Hi everyone, I'm brand new to this forum.
I just received a denial letter from my insurance company (Network Health) which is a faction of Mass Health in Massachusetts. This is the famous state-funded health care that became the model for our national Affordable Care Act health care.

The specific reason for denial is : I don't meet their guidelines for Harvoni requiring that the patient has stage 3 or 4 hepatic fibrosis. I have stage 1, therefore I have been denied.

I have Hep C type 1a. I just had a fibroscan 3 weeks ago and scored a low 4.5.
My viral load 2 years ago at diagnosis was 206 252 copies but 3 weeks ago the numbers reduced to 112 155. Apparently I'm "too healthy" to qualify for Harvoni. Not sure how I feel about it all at this point but I'm willing to reapply to Mass Health and (then to CareMark) to get what I 'm told will be another denial, then contact Gilead to see if they'll foot the bill for my 8 week Rx. This is what my doc suggests and I'm on board with it.

I've never been treated, am an entirely healthy 57-yr old in every other regard.
It's a real pity that the health of an individual sits in the scales of profit margins and... dare I say it?.... greed.
Best regards to all here and I pray that each finds the help and cure that is certainly deserved.

Oh.. does anyone have information that could explain why my viral load is reducing? I asked my doctor and he said "the numbers always fluctuate". They went up a bit the 2nd year of testing but are now half of what they were at diagnosis in 2012.

[Tess1971]

Mine fluctuated in only the thousands for years, but, after decades went to the millions as I got older.

[zeena]

hi toward health.
                 I just saw my doctor today, and asked him if I had  viral loads in the millions he said yes, but it fluctuated. sometimes thru exercise and good eating i got it to zero. then , stress and wine would skyrocket the number into the millions or hundreds of thousounds. I am in my last month of meds. riba and sol. .Just started my first course  of anti hep drugs in june.I must say ,mind activity , when not impoverished by exhaustion is much better. my writing still sucks.This is a friggin roller coaster of good days and bad days.or  high and low in one day. or before and after meds, or...I wish we could be transparent about having this. it would feel better.I mean outside of here.

[towardhealth]

Hi Tess, Thank you for letting me know about the progression of the viral load. So, it seems inevitable that the virus, if left untreated, will replicate more and more over the years. ugh.

Hi Zeena. thank you so much also for your input. I wonder if in my case I'm also seeing a dip in my viral load because of my very clean eating habits this past year. Though I'm not a drinker/smoker/or drug user, I do fall prey to stress big time. I'll have to work on keeping my focus on calmer thoughts as a preventative measure

BTW,  your writing doesn't suck at all...and as far as being transparent outside of forums like these, if it's any comfort, you can count on me to speak up for the lot of us. I'm drafting a letter to my Senator Elizabeth Warren to ask for her help in bringing this issue of insurance denial to light in DC.
Yes, the stigma of having hepatitis and speaking about its effects to our co-workers and friends is definitely unfortunate but I believe with time and national discussions, we're likely to see some changes in that. Keep the faith.

[zeena]

thumbs up!

[lporterrn]

Quite a few questions in this thread, but here are some quick answers.
Viral load goes up and down and it is a meaningless number - it does not correlate to anything, regardless if it is tens of thousands or tens of millions. It is frequently at its lowest when you are in total liver failure. Ignore this # unless you are on treatment - then it matters.

If you get a denial for treatment, please PM AndrewHCVGuy - he is taking on this project...

[jarrudy]

Hi all,
Update for those with Blue Cross Blue Shield, and the process:

The pharmacy team at the hospital has gathered the needed letter from the doctor, and other medical records to show that it is a medical necessity.

Blue cross blue shield requires that the member initiate an appeal (as opposed to most other insurance companies where the doctor's office can). They also required that I fax a letter requesting the appeal ( a phone verbal will not do). Everything has been submitted, and now it goes to an independent doctor to review and approve/deny. So, we wait.

Lots of hoops to jump through, and BCBS seems to be making us jump through plenty.

I asked at the hospital which insurance company has been easiest to deal with: United Healthcare. It's not an option for me, but thought others could benefit from that info.

[Surf Till U Die]

   If there a  BCBS  FL rep lurker that check this site pay attention!!!! 
       Up date I just got of phone with my Hepc Nurse practitioners to see how my appeals is going. She said it was summited on Mon 11th Nov now just waiting
        I then brought up how on hepc forms that I read how BCBS was rejecting almost all Harvoni request . Her reply was yes they were the worst I said Florida she said no all BCBS She know Tex/CAL ect ect. So I told her here were I stand. I do not have curious/cancer  yet as soon as I cross that line (have curious). I will find a attorney that will file suite against Blue Cross Blue Shield FL for a minimum of 100 Million dollars. For destroying my life when there is a cure out there that could have preventive me from having a deliberating chronic disease ( IE lost quality of life and possible premature death )  Her reply was if it get to that point she has more patience that she would put me in touch with. That would join me. I think that $100 Million per patience sounds  about right. Her reply was go get them. 
   If you lay out a case like we have how many juries would side with BCBS. I say none. All you have to do is say 95% cure rate for geno type 1a 1b
   And for those that are in the F3 and higher that are denied I wouldn't wait. I would be seeking a attorney right now they BCBS are playing with YOUR Life.   
   Lucinda  if you want to put this post some were else didn't know if I should start new thread.   

      See I truly  want to Surf till I Die with my children        John   

        in 2009 LIVER BIOPSY
HEPATITIS C NOS.
Liver, needle biopsy: Portal and lobular hepatitis (grade 2, stage 2).
Comment: Trichrome stain confirms mild portal fibrosis. Iron stain is
negative.
REN/lad

[lporterrn]

John -
I have been out of the loop with my own family issues, so forgive me if you said this before - do you have a more recent assessment of HCV progression than a 5+ y/o biopsy - either by fibroscan, serum markers or biopsy? Liver damage does not progress in a linear fashion, and tends to progress rapidly with age. There is a huge difference between what happens in 5 years to a 20 y/o versus a 60 y/o.

If you have not had anything more recently, I suggest a noninvasive procedure - fibroscan is not always available, but better than a biopsy.

[jarrudy]

Update: appeal was approved!!! Start treatment next week. Cannot believe it, still a bit in shock. I was prepared for the appeal denial, and then to have to contact Gillead to try to work with them for approval, etc.
It was alot of work (researching options, the criteria, the legal avenues, etc.) but I have to thank this board, ya'll were/are very helpful. I got alot of information from here that helped. Also, I found that lots and lots of conversations with the insurance company did help. I got alot of clues into what would be an exemption that would be accepted, and also a good look into the process so I could keep on it. I just kept digging and asking questions.
Dilligence pays off. That, and do not wait for your doc/hospital and the insurance companies to call you. Call them. Keep notes. Keep the conversation going. It helped, at least in my case.

[lporterrn]

Yahoo!!

[BattleTheBeast]

Congrats!! Way to advocate for yourself!!

[Surf Till U Die]

        Lucinda
   fibroscan  Is it were they take instrument that is  like a ultrasound. That is place between your ribs and thumps and it measure how the  sound waves pass through your liver and how pliable  you liver is??  If so had that done 2 month ago. The result were no curious.
           Surf John

[lporterrn]

yes Surf John, that is fibroscan

[bepper]

I worked for BCBS and MetLife in medical claims for many of my working years. Although I've been out a few years now, I know some things are still done the same.

When anything comes back denied from any insurance company, follow the appeal directions on the denial letter and appeal, appeal, appeal.

Many claims are processed without human touch, so a computer makes decisions as it is programmed to do with the info given. When working there, I've seen so many times the Drs office uploads their claims to the ins co with an incorrect procedure or diagnosis code in their system that causes the claim to be denied or paid at the incorrect level.
Then the Drs office staff then conveniently bills the patient. I am sure a lot of people just pay what they are billed and move on with their day. I can't tell you how many times my experience working inside the guts of the office has helped me get my claim processed correctly.

For awhile, I didn't see them as trying to get out of paying as much as following said policy guidelines. There are real people working at those offices with a number they need to process every day to keep their jobs.

I had to fight a claim myself a few years ago, knowing it was sent in with an incorrect code or procedure, can't remember now, but it took forever to get the office staff to understand how to submit the bill correctly. It finally worked out, but the aggravation when collection threats come in is beyond frustrating. I didn't like appearing as a deadbeat that didn't want to pay my bill. No, I didn't, I wanted my insurance company to pay, as they finally did.   

It's the big suits in the background that make the policy guidelines for the rest of us to live by. But that's a topic for another day.

bepper