Does prior non response help with insurance approval?

[sieb]

Hi new to this site but not hepatitis c. Was diagnosed in 1992 as non a or b. I am geno type 1a. I am a non responder twice once to interferon alone and once to interferon plus rib. Have had two biopsy one in 1995 and one in 2006 both show minimal inflammation. Just found out about Harvoni and made appointment with my Dr. He wants to start me on Harvoni and has submitted paper work to my insurance. My biopsy results do not show any "f" score just some Knodell score which is 4. I guess odds are slim to none for insurance coverage. My last attempt non response was in 1996. I was wondering if being a non responder would improved my chances of my insurance approval. Thanks.

[kotlbland]

Hello ,
I am very new to this site also. I am trying to write my insurance company on my own because Doctors office said its my responsibility.
I had a test called Fibrosure. This was a blood test that gave me my
Fibrosis stage " F4" and my Fibrosis score ".91". My doctor had this test done to see if prescription would go through. After 1 denial from insurance company he left it up to me.
The Test name is, HEPATITIS C VIRUS (HCV) FIBROSURE.
Hope this helps. Don't give up. John

[sieb]

Hi, yes it's been awhile since I really have read up on all the new test out there. I have talked to my insurance company Friday and they were going to contact my doctor. So just keeping fingers crossed. My age is 62 male without any real affects of the virus so I have been lucky. My doctor and I have waited for something better to come along like Harvoni the injections were getting old. Hope all works out for you.

[kotlbland]

Yes  think so. However think you need to back that up with other data.
Just the fact that I am a non responder wont help me because I've been denied. If your doctor feels you need it for your health and your denied 2x support path will help you get it w/out ins.


John

[kotlbland]

Yes  think so. However think you need to back that up with other data.
Just the fact that I am a non responder wont help me because I've been denied. If your doctor feels you need it for your health and your denied 2x support path will help you get it w/out ins.


John

[apache]

I am very new to this site also. I am trying to write my insurance company on my own because Doctors office said its my responsibility.

Wow, that's crazy.

However having said that, I should point out that doctors offices seem to vary widely in their tenacity when it comes to dealing with insurance companies.  Why?  Because the doctor has to basically eat the cost for the time spent dealing with the insurance company.   They can't bill that time to you, or to the insurance company.

My first dr was almost (but not quite) as bad as yours, regarding apathy when dealing with insurance denials.  So I changed providers.  I went to a completely different medical group, not to another provider in the same organization as my original doctor.  When "interviewing" the new doctor, I told them that I realize they don't get compensated for the time spent dealing with insurance, and so I was willing to pay for an extra office visit to help compensate.  The dr. was very grateful for my offer, but said that she actually has two nurses whose full time job is to deal with the insurance hassles.  And sure enough, she was the one who was able to get my Harvoni Rx approved.

So the lesson I learned is:  don't be afraid to change doctors.

[sieb]

I know its early in the process for me but my doctor told me basically the same thing he has people that deal with insurance and all the other paper work. I guess all he does after the office visit is write the script and monitor what goes on. I asked about denials and said at this point not to worry. Last thing before I left he said see you in 3 months.. go figure.. Thanks for the replays

[Lynn K]

Hi and welcome

Being F4 means you have cirrhosis that will help a lot to be qualified as well as being a prior non responder

For folks without cirrhosis getting approved results vary a big factor is which insurance company you have and what their treatment approval protocol

[sieb]

I have United Health Care which I hear is hard to qualify with. Oh well its in someone else hands now Thanks for all the responses. Wonder if I should as doc about fibrosure blood exam?

[Lynn K]

Most recently I had a fibroscan similar to ultrasound non invasive

Better than the 4 liver biopsies I had previously over the years

[dragonslayer]

Most recently I had a fibroscan similar to ultrasound non invasive

Better than the 4 liver biopsies I had previously over the years

Better for you , Lynn, because Fibroscan is pretty accurate with F4 assessments.. But for those in the F1-F3 ranges, results seem not great.  In the lower to mid range, Id hate to be scored an F2 if Im really an F0.  Or vice versa.  I think as a check for cirrhosis its probably useful, but if youre in the lower range, probably better off going with a biopsy if accuracy is the main goal.  Not that its without issue either. 

Id like to try a Fibroscan, but with my f0-1 biopsy result in 2013, Im afraid of the inaccuracies at that level. If there's some new accuracy data Im not aware of, please link me.. Thanks.

[Lynn K]

I was just saying the fibroscan was better than a biopsy in that it was less invasive and did not involve a big needle.

I thought I have read the fibrosure has its own accuracy issues in the lower ranges as well but I could be confusing that with something else.

Of course I guess for folks at the lower end could always have a biopsy for more accurate staging.

[Tpropane]

F4 (fibroscan, fibrosure, biopsy or MRI) and Non Responder you should get Harvoni for 24 weeks. That's the treatment length for us. Don't give up. I was denied 3 times. With the best PPO insurance I've ever had. I asked my doctor, "If I was was your wife, sister, mother...what would you do to help them get the drug that might save them them from liver failure?" In writing. A phone call can't be evidence. If They won't give you their email (a lot of doctors won't) send a written letter. Outlining that you are a perfect candidate for recommendation for Harvoni. And beg for their help in writing. 24 weeks. 24 weeks. I originally got approved for 12, I refused until I had the recommended dose approved. My doctors receptionist always acts like I am bothering her. So I went around her. I think that she thought that what I was asking was just too much work for her. I had to fight for the 24 weeks. Which is the protocol on the Gilead website. I'm not even sure my doctor knew what the protocol was...They should fight for you. You should fight for you. I called my insurance and said we never received your this or that test.(thanks receptionist) Get copies of every test and fax them to them directly. Get a name of a person on the Hep C harvoni team at your insurance company. "Who am I speaking to?" Accountability. Ask them what information they are missing. Get it from your doctor or the clinic who ran the tests and fax it yourself. Find out who your insurance companies' specialty pharmacy is. Make sure they are applying to the right pharmacy. Critical. My doc was applying to a local specialty pharmacy but my insurance preferred ACCREDO.  Plus I got a 5$ copay coupon from Harvoni. ON MYSUPPORTPATH.COM Which the first person at Accredo said we don't take coupons. and I went over her head. They took the coupon.
Above all be certain that you are right and they are missing some information. How can you help them understand. Also saying how you feel in the letter helps. Brown pee, upper right quadrant abominable pain, fatigue, headache, rapid heart rate. All true in my case.
8 weeks on Harvoni on St. Paddy's. Everyone says how much better I look. I know 24 weeks is going to slay the dragon. Though my major side effect is fatigue. If you are a full time employee supporting your family I have seen help with unraveling disability programs for Hep C on the internet. Im lucky I can work from home.
TPROPANE

[charly8]

Just to show the inaccuracies of these tests.  Note the following:

Fibrosure: December 2014 indicated F3
Fibroscan: March 2015 indicated F0 - F1 (3 months later)



My last biopsy showed F0 to F1 in 2011.

So what am I?

[Lynn K]

I have always heard the biopsy is the "gold standard" buthe person to ask would be your doctor what they think

[charly8]

I have always heard the biopsy is the "gold standard" buthe person to ask would be your doctor what they think

My doctor said the Fibrosure can be inaccurate (and usually to the upside), that is why we ordered the Fibroscan.   I was pleasantly surprised when he told me the Fibroscan score.  I am surprised about such a big discrepancy, from F3 to F0,1 is HUGE. 

[Lynn K]

As Dragon Slayer said above the Fibroscan is less accurate at the lower ranges and the best test although not without its own accuracy problems remains the biopsy.

Both the fibroscan and fibrosure are attepts to try to determine liver damage less invasively than a biopsy but are most accurate for F4 cirrhosis than F2

How does your doctor interpretate your various results?

[charly8]

I have not spoke to the doctor yet, the nurse practitioner has just told me the results and sent the results in hard copy.  Any good questions I should ask him when I do speak with him? 

My only question is maybe the fact that I am on treatment for 7 weeks and have lower ALT's has affected the stiffness, and may not represent the true Fibrosis level?

From my reading the biopsy is the most accurate as well, but only tests a small potion of the liver.  The fibroscan would be the next best followed by the fibrosure.

One benefit of the fibroscan is it measures a larger portion of the liver than the biopsy, although most of the time the liver has consistent damage throughout, but not always.   

[Lynn K]

dunno if I did a fibroscan I doubt mine would be any different but I have a lot of damage