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Author Topic: Appeal, Appeal, Appeal  (Read 23404 times)

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Offline BDK

  • Member
  • Posts: 58
  • "Appeal, Appeal, Appeal!"
Appeal, Appeal, Appeal
« on: July 01, 2015, 10:05:39 pm »
Today I received a letter from the independent medical review company, saying that the denial of Harvoni by Anthem had been overturned and my request was approved!  It has been a hugely long process but I want to write about it (short version) to encourage everyone to go as far with appeals as you can.

I got the script for Harvoni in Nov 2014 and it was denied by Anthem. I had an HMO with them at the time.  I appealed.  The appeal was denied ( = 2nd denial). It was now Jan 2015 and I had a different type of health plan (an EPO thru work) but still Anthem.

I tried Support Path but that was denied, and my appeal to them was also denied (over the $100,000 household income limit).

I requested an independent external medical review from the CA Dept of Managed Care, because I was originally on the HMO.  They referred me to the CA Dept of Insurance, who called me to say that because I had an EPO now, I should request an external review directly from Anthem. 

I wrote to Anthem at all the addresses I had for them, return receipt, requesting an independent review.  They are supposed to respond within 6 working days.  Three weeks later, no response so I mailed out more return receipt letters, requesting a response.  Within 5 days of that, I got a letter from the independent review company saying that I had been accepted for a review and to submit any other material, which I did.  I included lab work, correspondence, and doctors' letters explaining why I couldn't take ribavirin and needed Harvoni.  I am F0-1 fibrosis, normal alt and ast, and high (over 12 million) viral load.

I got the letter today saying the reviewer approved my request. In it, s/he stated that the treatment was necessary because it would provide medical benefit and not taking it would adversely affect my health, that the health plan should cover the treatment, that s/he had sufficient info to make that decision, that it was medically necessary according to my health insurance's certificate, and that there were no alternative therapies.  All these answers were backed up by research papers that the reviewer cited and quoted.

Now I will give Anthem a few days to pay up, or I will be on their case yet again!

So, if you've had denials and haven't requested an external review, I highly encourage it.  Cheers!  Barbara

 
Logged
Genotype 1a
Diagnosed 1992
Liver biopsy 1998 stage 0-1.
Peg inf + riba 1999, stopped at 25 weeks due to side effects-undetected then but reappeared within 3 months.
Liver biopsy 2006 - stage 0-1.
Fibroscan 2015 - stage 0-1.
VL >12 million.
AST, ALT high normal range.
7/17/15 Started Harvoni for 12 weeks.
8/4/15   VL 70, AST 19, ALT 11
9/17/15 VL Undetected (<12), AST 19, ALT 16
11/10/15 EOT +5 weeks VL Undetected (<12), AST 16, ALT 14
1/12/16 EOT + 14 weeks VL Undetected (<12)

Offline sapphire101

  • Member
  • Posts: 238
  • "Stop worrying and start living"
Re: Appeal, Appeal, Appeal
« Reply #1 on: July 02, 2015, 01:03:30 am »
Double cheers Barbara!!
Thank you for posting and let us know when you start treatment.
Logged
Sapphire101
Genotype 1a Fibrosis level 1
Viekira Pak with ribavirin 12 weeks
Pre treatment  VL  1.7 million, AST 45 ALT 65
EOT VL not detected, AST 21 ALT 21
12 week SVR not detected,24 week SVR not detected.
Cured! Class of 2015

Offline BDK

  • Member
  • Posts: 58
  • "Appeal, Appeal, Appeal!"
Re: Appeal, Appeal, Appeal
« Reply #2 on: July 02, 2015, 11:04:52 am »
Thanks Sapphire!  What a trip it has been so far. 
Logged
Genotype 1a
Diagnosed 1992
Liver biopsy 1998 stage 0-1.
Peg inf + riba 1999, stopped at 25 weeks due to side effects-undetected then but reappeared within 3 months.
Liver biopsy 2006 - stage 0-1.
Fibroscan 2015 - stage 0-1.
VL >12 million.
AST, ALT high normal range.
7/17/15 Started Harvoni for 12 weeks.
8/4/15   VL 70, AST 19, ALT 11
9/17/15 VL Undetected (<12), AST 19, ALT 16
11/10/15 EOT +5 weeks VL Undetected (<12), AST 16, ALT 14
1/12/16 EOT + 14 weeks VL Undetected (<12)

Offline Else

  • Member
  • Posts: 523
  • Appeal, appeal, and appeal again!
Re: Appeal, Appeal, Appeal
« Reply #3 on: July 03, 2015, 03:33:40 pm »
Congrats!  And good for you for staying in the fight!!!
Logged
F/53 yr
diagnosed 1995
Genotype 1a
ALT: 58 AST: 39 ALK: 105
Viral load 4,201,950 IU/ml
Fibroscan 6.5 (F1-F2) Fibrosure 0.36 (F1-F2)
Treatment-naive
After 3 denials, finally approved!
Harvoni 12 wks - start date 9/15/15
4 wk labs 10/14/15
ALT: 12 AST: 16 ALK: 85
HCV Not Detected!!!
8 wk labs 11/10/15
ALT: 13  AST: 15  ALK: 77
12 wk (EOT!) labs 12/8/15
ALT: 11 AST: 15 ALK: 78
HCV Not Detected!!!
10wk posttx labs 2/11/16
ALT: 22 AST: 17 ALK: 61
HCV Not Detected!! SVR10!!!
SVR10 (99.7% Cured!!!)

Offline BDK

  • Member
  • Posts: 58
  • "Appeal, Appeal, Appeal!"
Re: Appeal, Appeal, Appeal
« Reply #4 on: July 15, 2015, 01:14:16 am »
Still fighting! No word from Anthem (who I am sure were copied on the Appeal decision). I called customer "service" and the nice lady asked me to email her the appeal approval, but never responded when i asked for verification that she got it. Also sent a copy to my gastro, who sent it to his specialty pharmacy. They called express Scripts, who said call Anthem grievances & Appeals.  Called them and they want a copy of the appeal approval mailed to them.  Mailed, not faxed or emailed.  Sheesh.  So I am fed-exing that tomorrow.  It's only been 9 months since my prescription was written...

And if I don't get an answer to "where is my Harvoni" soon, I shall start lawyering up :-)
Logged
Genotype 1a
Diagnosed 1992
Liver biopsy 1998 stage 0-1.
Peg inf + riba 1999, stopped at 25 weeks due to side effects-undetected then but reappeared within 3 months.
Liver biopsy 2006 - stage 0-1.
Fibroscan 2015 - stage 0-1.
VL >12 million.
AST, ALT high normal range.
7/17/15 Started Harvoni for 12 weeks.
8/4/15   VL 70, AST 19, ALT 11
9/17/15 VL Undetected (<12), AST 19, ALT 16
11/10/15 EOT +5 weeks VL Undetected (<12), AST 16, ALT 14
1/12/16 EOT + 14 weeks VL Undetected (<12)

Offline Else

  • Member
  • Posts: 523
  • Appeal, appeal, and appeal again!
Re: Appeal, Appeal, Appeal
« Reply #5 on: July 15, 2015, 01:41:20 pm »
Good on ya for your energy, Barbara!

Have you contacted the company that did the independent review?  If the reviewer went so far as to cite research papers on your behalf, he/she might be interested in the fact that their decision carries no weight with Anthem.

While you're pursuing action on the first independent review via Anthem and FedEx, maybe asking the independent view company if they have someone in a "supervisory position who can approval the appeal approval in writing since their decision is apparently irrelevant Anthem."

Maybe that would motivate someone there to make some calls on your behalf?  Just thinkin' out loud.
Logged
F/53 yr
diagnosed 1995
Genotype 1a
ALT: 58 AST: 39 ALK: 105
Viral load 4,201,950 IU/ml
Fibroscan 6.5 (F1-F2) Fibrosure 0.36 (F1-F2)
Treatment-naive
After 3 denials, finally approved!
Harvoni 12 wks - start date 9/15/15
4 wk labs 10/14/15
ALT: 12 AST: 16 ALK: 85
HCV Not Detected!!!
8 wk labs 11/10/15
ALT: 13  AST: 15  ALK: 77
12 wk (EOT!) labs 12/8/15
ALT: 11 AST: 15 ALK: 78
HCV Not Detected!!!
10wk posttx labs 2/11/16
ALT: 22 AST: 17 ALK: 61
HCV Not Detected!! SVR10!!!
SVR10 (99.7% Cured!!!)

Offline BDK

  • Member
  • Posts: 58
  • "Appeal, Appeal, Appeal!"
Re: Appeal, Appeal, Appeal
« Reply #6 on: July 15, 2015, 02:05:28 pm »
Thanks Else.  I let the ind review company know what is going on today.  They confirmed that they had copied Anthem on the approval.  I am sure it is Anthem obfuscating (or whatever the word is!).
Logged
Genotype 1a
Diagnosed 1992
Liver biopsy 1998 stage 0-1.
Peg inf + riba 1999, stopped at 25 weeks due to side effects-undetected then but reappeared within 3 months.
Liver biopsy 2006 - stage 0-1.
Fibroscan 2015 - stage 0-1.
VL >12 million.
AST, ALT high normal range.
7/17/15 Started Harvoni for 12 weeks.
8/4/15   VL 70, AST 19, ALT 11
9/17/15 VL Undetected (<12), AST 19, ALT 16
11/10/15 EOT +5 weeks VL Undetected (<12), AST 16, ALT 14
1/12/16 EOT + 14 weeks VL Undetected (<12)

Offline Else

  • Member
  • Posts: 523
  • Appeal, appeal, and appeal again!
Re: Appeal, Appeal, Appeal
« Reply #7 on: July 15, 2015, 02:49:43 pm »
Well, that's the polite word.  I can think of others.  ;)
Logged
F/53 yr
diagnosed 1995
Genotype 1a
ALT: 58 AST: 39 ALK: 105
Viral load 4,201,950 IU/ml
Fibroscan 6.5 (F1-F2) Fibrosure 0.36 (F1-F2)
Treatment-naive
After 3 denials, finally approved!
Harvoni 12 wks - start date 9/15/15
4 wk labs 10/14/15
ALT: 12 AST: 16 ALK: 85
HCV Not Detected!!!
8 wk labs 11/10/15
ALT: 13  AST: 15  ALK: 77
12 wk (EOT!) labs 12/8/15
ALT: 11 AST: 15 ALK: 78
HCV Not Detected!!!
10wk posttx labs 2/11/16
ALT: 22 AST: 17 ALK: 61
HCV Not Detected!! SVR10!!!
SVR10 (99.7% Cured!!!)

Offline Scoutdoy

  • Member
  • Posts: 452
Re: Appeal, Appeal, Appeal
« Reply #8 on: July 15, 2015, 04:21:02 pm »
It is ridiculous that people have to go through the stress of getting their insurance company to actually take care of them. Honestly I would be lawyering up now...once that approval went through you should of had your medicine within days how dare them ...withholding your medicine from you...I start Harvoni on July 23... Hopefully we can start treatment at the same time and beat the beast!!
Logged
F/49yrs
Genotype 1a
infected 1987-tatoo/military?
Diagnosed 2007
Biopsy F-0
vl 13,900,000
AST 23
ALT 19
Harvoni Treatment 7/27/2015
4 week lab --<12 negative...AST 23 ALT 15
6 week lab -- Undetected.....AST 17 ALT 10
8 week lab---undetected.......AST15 Alt 10
12 week lab---UNDETECTED....AST 15 ALT 9
12 week EOT--1/13/2016----UNDETECTED!
24 week EOT ----UNDETECTED  --AST 18 ALT 12
I AM FREE!

Offline BDK

  • Member
  • Posts: 58
  • "Appeal, Appeal, Appeal!"
Re: Appeal, Appeal, Appeal
« Reply #9 on: July 16, 2015, 07:09:00 pm »
Harvoni arrives tomorrow!  I think my email to the VP of benefits for my employer did the trick. She said she'd call Anthem on my behalf. Express Scripts called my specialty pharmacy, ADRZ, today. Onwards!
Logged
Genotype 1a
Diagnosed 1992
Liver biopsy 1998 stage 0-1.
Peg inf + riba 1999, stopped at 25 weeks due to side effects-undetected then but reappeared within 3 months.
Liver biopsy 2006 - stage 0-1.
Fibroscan 2015 - stage 0-1.
VL >12 million.
AST, ALT high normal range.
7/17/15 Started Harvoni for 12 weeks.
8/4/15   VL 70, AST 19, ALT 11
9/17/15 VL Undetected (<12), AST 19, ALT 16
11/10/15 EOT +5 weeks VL Undetected (<12), AST 16, ALT 14
1/12/16 EOT + 14 weeks VL Undetected (<12)

Offline Else

  • Member
  • Posts: 523
  • Appeal, appeal, and appeal again!
Re: Appeal, Appeal, Appeal
« Reply #10 on: July 16, 2015, 07:43:16 pm »
 ;D  Congrats beyond all reason!!!  That is wonderful news.  You're a real testament to what perseverance can do!!!
Logged
F/53 yr
diagnosed 1995
Genotype 1a
ALT: 58 AST: 39 ALK: 105
Viral load 4,201,950 IU/ml
Fibroscan 6.5 (F1-F2) Fibrosure 0.36 (F1-F2)
Treatment-naive
After 3 denials, finally approved!
Harvoni 12 wks - start date 9/15/15
4 wk labs 10/14/15
ALT: 12 AST: 16 ALK: 85
HCV Not Detected!!!
8 wk labs 11/10/15
ALT: 13  AST: 15  ALK: 77
12 wk (EOT!) labs 12/8/15
ALT: 11 AST: 15 ALK: 78
HCV Not Detected!!!
10wk posttx labs 2/11/16
ALT: 22 AST: 17 ALK: 61
HCV Not Detected!! SVR10!!!
SVR10 (99.7% Cured!!!)

Offline Scoutdoy

  • Member
  • Posts: 452
Re: Appeal, Appeal, Appeal
« Reply #11 on: July 16, 2015, 08:58:41 pm »
That's fantastic...we will be going thru treatment at the same time congrats!!
Logged
F/49yrs
Genotype 1a
infected 1987-tatoo/military?
Diagnosed 2007
Biopsy F-0
vl 13,900,000
AST 23
ALT 19
Harvoni Treatment 7/27/2015
4 week lab --<12 negative...AST 23 ALT 15
6 week lab -- Undetected.....AST 17 ALT 10
8 week lab---undetected.......AST15 Alt 10
12 week lab---UNDETECTED....AST 15 ALT 9
12 week EOT--1/13/2016----UNDETECTED!
24 week EOT ----UNDETECTED  --AST 18 ALT 12
I AM FREE!

Offline BDK

  • Member
  • Posts: 58
  • "Appeal, Appeal, Appeal!"
Re: Appeal, Appeal, Appeal
« Reply #12 on: July 16, 2015, 09:48:20 pm »
Thanks - so excited!  My doc wants to see me just over 2 weeks after I start for bloods - not sure I want to know any results though at that point.  Scoutdoy, let's keep in touch!  The pharmacist I spoke to, said some people take it with food, and some take it in the morning rather than at night, because they find it keeps them awake.  Drink lots of water, and don't take St Johns Wort or any kind of antacid.  If you do need to take an antacid, wait at least 4 hours after taking Harvoni.
Logged
Genotype 1a
Diagnosed 1992
Liver biopsy 1998 stage 0-1.
Peg inf + riba 1999, stopped at 25 weeks due to side effects-undetected then but reappeared within 3 months.
Liver biopsy 2006 - stage 0-1.
Fibroscan 2015 - stage 0-1.
VL >12 million.
AST, ALT high normal range.
7/17/15 Started Harvoni for 12 weeks.
8/4/15   VL 70, AST 19, ALT 11
9/17/15 VL Undetected (<12), AST 19, ALT 16
11/10/15 EOT +5 weeks VL Undetected (<12), AST 16, ALT 14
1/12/16 EOT + 14 weeks VL Undetected (<12)

Offline Scoutdoy

  • Member
  • Posts: 452
Re: Appeal, Appeal, Appeal
« Reply #13 on: July 16, 2015, 09:55:14 pm »
I am starting mine on wed July 22nd..had a slight change in plans...daughter is having surgery to fix an ankle broken playing rugby. I haven't decided to take at night or in the morning yet.  I have had people comment on both. I am really excited to get started thou I can tell you that....ready...set ...go ....off to a cure...LOL
Logged
F/49yrs
Genotype 1a
infected 1987-tatoo/military?
Diagnosed 2007
Biopsy F-0
vl 13,900,000
AST 23
ALT 19
Harvoni Treatment 7/27/2015
4 week lab --<12 negative...AST 23 ALT 15
6 week lab -- Undetected.....AST 17 ALT 10
8 week lab---undetected.......AST15 Alt 10
12 week lab---UNDETECTED....AST 15 ALT 9
12 week EOT--1/13/2016----UNDETECTED!
24 week EOT ----UNDETECTED  --AST 18 ALT 12
I AM FREE!

Offline KimInTheForest

  • Member
  • Posts: 1,972
  • Believe in yourself
Re: Appeal, Appeal, Appeal
« Reply #14 on: July 16, 2015, 10:25:15 pm »
Quote from: BDK on July 16, 2015, 07:09:00 pm
Harvoni arrives tomorrow!  I think my email to the VP of benefits for my employer did the trick. She said she'd call Anthem on my behalf. Express Scripts called my specialty pharmacy, ADRZ, today. Onwards!

Congratulations BDK! You did it. What an example you have set for fighting for your treatment no matter how long it takes and how many road blocks an insurer throws up along the way. Ridiculous that any of us should have to fight to get cured, yet so many people are in precisely that position.

Good luck on your Harvoni journey!
kim :)
Logged
Kim Goldberg (Nanaimo, BC)
1970s: Contracted HCV (genotype 3a)
2015: Cured with Harvoni + ribavirin (12 weeks)
MY STORY: https://pigsquash.wordpress.com/2016/01/28/undetectable-my-hep-c-story/

Offline BDK

  • Member
  • Posts: 58
  • "Appeal, Appeal, Appeal!"
Re: Appeal, Appeal, Appeal
« Reply #15 on: July 16, 2015, 11:30:41 pm »
Thanks Kim!  I hope the treatment continues to go well for you too.
Logged
Genotype 1a
Diagnosed 1992
Liver biopsy 1998 stage 0-1.
Peg inf + riba 1999, stopped at 25 weeks due to side effects-undetected then but reappeared within 3 months.
Liver biopsy 2006 - stage 0-1.
Fibroscan 2015 - stage 0-1.
VL >12 million.
AST, ALT high normal range.
7/17/15 Started Harvoni for 12 weeks.
8/4/15   VL 70, AST 19, ALT 11
9/17/15 VL Undetected (<12), AST 19, ALT 16
11/10/15 EOT +5 weeks VL Undetected (<12), AST 16, ALT 14
1/12/16 EOT + 14 weeks VL Undetected (<12)

Offline Else

  • Member
  • Posts: 523
  • Appeal, appeal, and appeal again!
Re: Appeal, Appeal, Appeal
« Reply #16 on: July 16, 2015, 11:44:32 pm »
Hi Barbara,

I'm about to start a Level 2 appeal myself for Harvoni.  That's amazing that the independent review board would overturn Anthem's staging priorities of F3-F4 fibrosis when you have F0-F1 with only slightly elevated liver enzymes.

Very clear-cut that Viekira Pak w/riba wasn't an option for you but how did you get them to approve Harvoni with your labs?  I'm really happy for you but I'm stunned.  Research journals cited?  Compelling letter of medical necessity?  Compelling letter of your own?  I would appreciate the heck out of any tips!

And happy sailing on your treatment - talk about well-earned!
Logged
F/53 yr
diagnosed 1995
Genotype 1a
ALT: 58 AST: 39 ALK: 105
Viral load 4,201,950 IU/ml
Fibroscan 6.5 (F1-F2) Fibrosure 0.36 (F1-F2)
Treatment-naive
After 3 denials, finally approved!
Harvoni 12 wks - start date 9/15/15
4 wk labs 10/14/15
ALT: 12 AST: 16 ALK: 85
HCV Not Detected!!!
8 wk labs 11/10/15
ALT: 13  AST: 15  ALK: 77
12 wk (EOT!) labs 12/8/15
ALT: 11 AST: 15 ALK: 78
HCV Not Detected!!!
10wk posttx labs 2/11/16
ALT: 22 AST: 17 ALK: 61
HCV Not Detected!! SVR10!!!
SVR10 (99.7% Cured!!!)

Offline BDK

  • Member
  • Posts: 58
  • "Appeal, Appeal, Appeal!"
Re: Appeal, Appeal, Appeal
« Reply #17 on: July 17, 2015, 12:23:01 am »
Else - I sent you a private message - hope to hear from you.  I can send you more info that might help you.
Logged
Genotype 1a
Diagnosed 1992
Liver biopsy 1998 stage 0-1.
Peg inf + riba 1999, stopped at 25 weeks due to side effects-undetected then but reappeared within 3 months.
Liver biopsy 2006 - stage 0-1.
Fibroscan 2015 - stage 0-1.
VL >12 million.
AST, ALT high normal range.
7/17/15 Started Harvoni for 12 weeks.
8/4/15   VL 70, AST 19, ALT 11
9/17/15 VL Undetected (<12), AST 19, ALT 16
11/10/15 EOT +5 weeks VL Undetected (<12), AST 16, ALT 14
1/12/16 EOT + 14 weeks VL Undetected (<12)

Offline Scoutdoy

  • Member
  • Posts: 452
Re: Appeal, Appeal, Appeal
« Reply #18 on: July 17, 2015, 12:25:01 am »
Hi Else,
     I too have good liver numbers and got approvall.  My hep doctor has a team in his office and their only job is to get people approved and work appeals. I don't know what they did but I am going to find out because I am getting a copy of everything in my file for at home when I go pick up my meds next Wednesday. I do know that every symptom I have ever had  (from joint pain to fatigue)was written down and logged along with my type of work, my being a single parent with young children still at home etc.... I will try to get the  letter they included in with the request. Sometimes with insurance it can depend on the way the doctor requests medicine. That is what they told me from the start and I will be dammed if I didn't get approved within 2 weeks of them submitting the information
Logged
F/49yrs
Genotype 1a
infected 1987-tatoo/military?
Diagnosed 2007
Biopsy F-0
vl 13,900,000
AST 23
ALT 19
Harvoni Treatment 7/27/2015
4 week lab --<12 negative...AST 23 ALT 15
6 week lab -- Undetected.....AST 17 ALT 10
8 week lab---undetected.......AST15 Alt 10
12 week lab---UNDETECTED....AST 15 ALT 9
12 week EOT--1/13/2016----UNDETECTED!
24 week EOT ----UNDETECTED  --AST 18 ALT 12
I AM FREE!

Offline Scoutdoy

  • Member
  • Posts: 452
Re: Appeal, Appeal, Appeal
« Reply #19 on: July 17, 2015, 12:28:44 am »
Good luck with your appeal Else....and if you get denied again do it again and again ...you will win eventually

Scout
Logged
F/49yrs
Genotype 1a
infected 1987-tatoo/military?
Diagnosed 2007
Biopsy F-0
vl 13,900,000
AST 23
ALT 19
Harvoni Treatment 7/27/2015
4 week lab --<12 negative...AST 23 ALT 15
6 week lab -- Undetected.....AST 17 ALT 10
8 week lab---undetected.......AST15 Alt 10
12 week lab---UNDETECTED....AST 15 ALT 9
12 week EOT--1/13/2016----UNDETECTED!
24 week EOT ----UNDETECTED  --AST 18 ALT 12
I AM FREE!

Offline Else

  • Member
  • Posts: 523
  • Appeal, appeal, and appeal again!
Re: Appeal, Appeal, Appeal
« Reply #20 on: July 17, 2015, 01:45:03 am »
Quote from: Scoutdoy on July 17, 2015, 12:25:01 am
Hi Else,
     I too have good liver numbers and got approvall.  My hep doctor has a team in his office and their only job is to get people approved and work appeals. I don't know what they did but I am going to find out because I am getting a copy of everything in my file for at home when I go pick up my meds next Wednesday. I do know that every symptom I have ever had  (from joint pain to fatigue)was written down and logged along with my type of work, my being a single parent with young children still at home etc.... I will try to get the  letter they included in with the request. Sometimes with insurance it can depend on the way the doctor requests medicine. That is what they told me from the start and I will be dammed if I didn't get approved within 2 weeks of them submitting the information

That is fantastic that you had a solid team behind you.  I do believe it makes all the difference.  I knew a great deal depended on the prior authorization request.  My Specialty Pharmacy intermediary did too and faxed my doc's office twice asking for a letter of medical necessity.  No response.  When I asked them they said they only do them in appeals.
My insurance is lightening fast.  It was denied in four days.  I was so foolish to let them handle the appeal after that.  But by that time I had placed all my hope in Support Path.  Apparently so did my doctor's office.  Oops.
But onwards and upwards.  Appeal, appeal, appeal.   :)

Congrats, Scout!
Logged
F/53 yr
diagnosed 1995
Genotype 1a
ALT: 58 AST: 39 ALK: 105
Viral load 4,201,950 IU/ml
Fibroscan 6.5 (F1-F2) Fibrosure 0.36 (F1-F2)
Treatment-naive
After 3 denials, finally approved!
Harvoni 12 wks - start date 9/15/15
4 wk labs 10/14/15
ALT: 12 AST: 16 ALK: 85
HCV Not Detected!!!
8 wk labs 11/10/15
ALT: 13  AST: 15  ALK: 77
12 wk (EOT!) labs 12/8/15
ALT: 11 AST: 15 ALK: 78
HCV Not Detected!!!
10wk posttx labs 2/11/16
ALT: 22 AST: 17 ALK: 61
HCV Not Detected!! SVR10!!!
SVR10 (99.7% Cured!!!)

Offline sapphire101

  • Member
  • Posts: 238
  • "Stop worrying and start living"
Re: Appeal, Appeal, Appeal
« Reply #21 on: July 20, 2015, 08:21:57 pm »
Congratulations BDK, I am very happy for you and I know that you have been at this a long time now. At least six months?
Please keep me posted on your progress on treatment and continue to share your story.
People need to hear your message - if they don't give up, they will get the medicines. Many times you were turned down and you just kept getting back up and trying again.
Logged
Sapphire101
Genotype 1a Fibrosis level 1
Viekira Pak with ribavirin 12 weeks
Pre treatment  VL  1.7 million, AST 45 ALT 65
EOT VL not detected, AST 21 ALT 21
12 week SVR not detected,24 week SVR not detected.
Cured! Class of 2015

Offline BDK

  • Member
  • Posts: 58
  • "Appeal, Appeal, Appeal!"
Re: Appeal, Appeal, Appeal
« Reply #22 on: July 20, 2015, 10:35:08 pm »
Thanks Sapphire - 9 months + 10 days from the time the prescription was written to the first pill in my mouth!  I tried every angle, some more than once.  My GI doc (Graham Woolf, MD in LA) was willing to try as well.  As well as Anthem, I wen to Express Scripts directly, that direct email to the Express Scripts lady (?Rita), and using 2 different specialty pharmacies, plus I tried Support Path, and then there were various appeals!  I never for one minute envisioned not getting it, I don't know why, but I certainly never gave up.

I think for Anthem at least, that they will automatically churn out the first denial and then the second denial to one's first appeal.  I have a stack of their response letters, and the wording is pathetic and in some cases makes no sense whatsoever - clearly those response letters had nothing to do with MY case.  I think that the first time attention got paid to my case personally was when I requested the independent medical review (IMR).  And if a doc ever tells someone that it's not worth appealing, do it anyway, you don't need her permission.  Just get through those 2 denials, then ask for the IMR!

So glad you're doing well too Sapphire!  Whew!

Logged
Genotype 1a
Diagnosed 1992
Liver biopsy 1998 stage 0-1.
Peg inf + riba 1999, stopped at 25 weeks due to side effects-undetected then but reappeared within 3 months.
Liver biopsy 2006 - stage 0-1.
Fibroscan 2015 - stage 0-1.
VL >12 million.
AST, ALT high normal range.
7/17/15 Started Harvoni for 12 weeks.
8/4/15   VL 70, AST 19, ALT 11
9/17/15 VL Undetected (<12), AST 19, ALT 16
11/10/15 EOT +5 weeks VL Undetected (<12), AST 16, ALT 14
1/12/16 EOT + 14 weeks VL Undetected (<12)

Offline Scoutdoy

  • Member
  • Posts: 452
Re: Appeal, Appeal, Appeal
« Reply #23 on: July 20, 2015, 10:52:45 pm »
Hey BDK how is your treatment going? I start mine on Wed night or Thursday morning depending on what time of day I take it. What time of day did you choose?

Scout
Logged
F/49yrs
Genotype 1a
infected 1987-tatoo/military?
Diagnosed 2007
Biopsy F-0
vl 13,900,000
AST 23
ALT 19
Harvoni Treatment 7/27/2015
4 week lab --<12 negative...AST 23 ALT 15
6 week lab -- Undetected.....AST 17 ALT 10
8 week lab---undetected.......AST15 Alt 10
12 week lab---UNDETECTED....AST 15 ALT 9
12 week EOT--1/13/2016----UNDETECTED!
24 week EOT ----UNDETECTED  --AST 18 ALT 12
I AM FREE!

Offline BDK

  • Member
  • Posts: 58
  • "Appeal, Appeal, Appeal!"
Re: Appeal, Appeal, Appeal
« Reply #24 on: July 20, 2015, 11:05:30 pm »
Hi Scout - so far so good.  I take it in the mornings, after a banana and my cup of tea (I'm British!), then the Harvoni about 30 minutes later.  The specialty pharmacy's pharmacist  said taking it after food helps some people if they get nauseous - I haven't had nausea but thought I'd be pre-emptive.  The pharmacist also said that some people find it keeps them awake if they take it at night. I do find I get a bit jittery, like tapping my foot repetitively as I sit at my computer doing work - probably totally unrelated, lol.  Haven't been more tired than usual, but have been more hungry.  No headaches. Who knows what are sides and what is just daily bodily goings-on!  Are you excited?  Let me know how your first week goes.
Logged
Genotype 1a
Diagnosed 1992
Liver biopsy 1998 stage 0-1.
Peg inf + riba 1999, stopped at 25 weeks due to side effects-undetected then but reappeared within 3 months.
Liver biopsy 2006 - stage 0-1.
Fibroscan 2015 - stage 0-1.
VL >12 million.
AST, ALT high normal range.
7/17/15 Started Harvoni for 12 weeks.
8/4/15   VL 70, AST 19, ALT 11
9/17/15 VL Undetected (<12), AST 19, ALT 16
11/10/15 EOT +5 weeks VL Undetected (<12), AST 16, ALT 14
1/12/16 EOT + 14 weeks VL Undetected (<12)

Offline Scoutdoy

  • Member
  • Posts: 452
Re: Appeal, Appeal, Appeal
« Reply #25 on: July 20, 2015, 11:13:25 pm »
Yes I am very excited especially because my viral load is so high. My 17 yr old has ankle surgery tomorrow and I go pick up medicine and have consultation with the doctor Wednesday afternoon.  I think I will do the am time...I I will probably start Thursday morning.  I already have difficulty sleeping...don't need to add any fuel to that fire...lol


Scout
Logged
F/49yrs
Genotype 1a
infected 1987-tatoo/military?
Diagnosed 2007
Biopsy F-0
vl 13,900,000
AST 23
ALT 19
Harvoni Treatment 7/27/2015
4 week lab --<12 negative...AST 23 ALT 15
6 week lab -- Undetected.....AST 17 ALT 10
8 week lab---undetected.......AST15 Alt 10
12 week lab---UNDETECTED....AST 15 ALT 9
12 week EOT--1/13/2016----UNDETECTED!
24 week EOT ----UNDETECTED  --AST 18 ALT 12
I AM FREE!

Offline Else

  • Member
  • Posts: 523
  • Appeal, appeal, and appeal again!
Re: Appeal, Appeal, Appeal
« Reply #26 on: July 21, 2015, 12:54:16 am »
Quote from: BDK on July 20, 2015, 10:35:08 pm
I have a stack of their response letters, and the wording is pathetic and in some cases makes no sense whatsoever - clearly those response letters had nothing to do with MY case.  I think that the first time attention got paid to my case personally was when I requested the independent medical review (IMR).  And if a doc ever tells someone that it's not worth appealing, do it anyway, you don't need her permission.  Just get through those 2 denials, then ask for the IMR!

The wording IS strange, isn't it?  :o 

"If you feel we have administered benefits incorrectly, you may request a second review of this appeal.  Your request should include a written statement of your position."

So am I actually appealing or requesting the right to a second appeal?  A request that they will take under consideration?  ???

It goes on, "You may also include any additional information to support the need for a second review and your desired outcome.  An in-house panel would conduct the second review." 

Again, it sounds like I'm appealing for the right to appeal a previous appeal.  Good grief.   :o 

Well, at least I'm clear on my desired outcome.  That's a start.  This forum is such a huge inspiration.  Congratulations to all the healed and the healing!
Logged
F/53 yr
diagnosed 1995
Genotype 1a
ALT: 58 AST: 39 ALK: 105
Viral load 4,201,950 IU/ml
Fibroscan 6.5 (F1-F2) Fibrosure 0.36 (F1-F2)
Treatment-naive
After 3 denials, finally approved!
Harvoni 12 wks - start date 9/15/15
4 wk labs 10/14/15
ALT: 12 AST: 16 ALK: 85
HCV Not Detected!!!
8 wk labs 11/10/15
ALT: 13  AST: 15  ALK: 77
12 wk (EOT!) labs 12/8/15
ALT: 11 AST: 15 ALK: 78
HCV Not Detected!!!
10wk posttx labs 2/11/16
ALT: 22 AST: 17 ALK: 61
HCV Not Detected!! SVR10!!!
SVR10 (99.7% Cured!!!)

Offline Scoutdoy

  • Member
  • Posts: 452
Re: Appeal, Appeal, Appeal
« Reply #27 on: July 21, 2015, 01:02:16 am »
Else...I am getting a copy of my paperwork on Wednesday and if there is some information or a specific terminology that was used to help my case I will shoot you a private email with the information Wednesday night


Scout
Logged
F/49yrs
Genotype 1a
infected 1987-tatoo/military?
Diagnosed 2007
Biopsy F-0
vl 13,900,000
AST 23
ALT 19
Harvoni Treatment 7/27/2015
4 week lab --<12 negative...AST 23 ALT 15
6 week lab -- Undetected.....AST 17 ALT 10
8 week lab---undetected.......AST15 Alt 10
12 week lab---UNDETECTED....AST 15 ALT 9
12 week EOT--1/13/2016----UNDETECTED!
24 week EOT ----UNDETECTED  --AST 18 ALT 12
I AM FREE!

Offline Else

  • Member
  • Posts: 523
  • Appeal, appeal, and appeal again!
Re: Appeal, Appeal, Appeal
« Reply #28 on: July 21, 2015, 01:43:12 am »
Thanks Scout!  And a speed recovery to your kiddo.   :)
Logged
F/53 yr
diagnosed 1995
Genotype 1a
ALT: 58 AST: 39 ALK: 105
Viral load 4,201,950 IU/ml
Fibroscan 6.5 (F1-F2) Fibrosure 0.36 (F1-F2)
Treatment-naive
After 3 denials, finally approved!
Harvoni 12 wks - start date 9/15/15
4 wk labs 10/14/15
ALT: 12 AST: 16 ALK: 85
HCV Not Detected!!!
8 wk labs 11/10/15
ALT: 13  AST: 15  ALK: 77
12 wk (EOT!) labs 12/8/15
ALT: 11 AST: 15 ALK: 78
HCV Not Detected!!!
10wk posttx labs 2/11/16
ALT: 22 AST: 17 ALK: 61
HCV Not Detected!! SVR10!!!
SVR10 (99.7% Cured!!!)

Offline Else

  • Member
  • Posts: 523
  • Appeal, appeal, and appeal again!
Re: Appeal, Appeal, Appeal
« Reply #29 on: September 11, 2015, 09:26:14 pm »
Bumping this thread for accuracy.  Appeal, appeal, appeal!!!

I'll make a new thread (and maybe even finally fill in my stats, heh) when I have the Harvoni in hand.  As things stand, that should be the middle of next week.

"The denial of services and/or payment of services by the plan has been OVERTURNED."

An Independent Review Organization finally set things right.  I am stunned and grateful. 
Logged
F/53 yr
diagnosed 1995
Genotype 1a
ALT: 58 AST: 39 ALK: 105
Viral load 4,201,950 IU/ml
Fibroscan 6.5 (F1-F2) Fibrosure 0.36 (F1-F2)
Treatment-naive
After 3 denials, finally approved!
Harvoni 12 wks - start date 9/15/15
4 wk labs 10/14/15
ALT: 12 AST: 16 ALK: 85
HCV Not Detected!!!
8 wk labs 11/10/15
ALT: 13  AST: 15  ALK: 77
12 wk (EOT!) labs 12/8/15
ALT: 11 AST: 15 ALK: 78
HCV Not Detected!!!
10wk posttx labs 2/11/16
ALT: 22 AST: 17 ALK: 61
HCV Not Detected!! SVR10!!!
SVR10 (99.7% Cured!!!)

Offline Scoutdoy

  • Member
  • Posts: 452
Re: Appeal, Appeal, Appeal
« Reply #30 on: September 11, 2015, 10:22:32 pm »
That's just great!!! You'll be on the cure train with the rest of us shortly....Congrats and good luck to you


Scout
Logged
F/49yrs
Genotype 1a
infected 1987-tatoo/military?
Diagnosed 2007
Biopsy F-0
vl 13,900,000
AST 23
ALT 19
Harvoni Treatment 7/27/2015
4 week lab --<12 negative...AST 23 ALT 15
6 week lab -- Undetected.....AST 17 ALT 10
8 week lab---undetected.......AST15 Alt 10
12 week lab---UNDETECTED....AST 15 ALT 9
12 week EOT--1/13/2016----UNDETECTED!
24 week EOT ----UNDETECTED  --AST 18 ALT 12
I AM FREE!

Offline BDK

  • Member
  • Posts: 58
  • "Appeal, Appeal, Appeal!"
Re: Appeal, Appeal, Appeal
« Reply #31 on: September 12, 2015, 01:08:25 am »
Just awesome news Else - I am SO happy for you!
Logged
Genotype 1a
Diagnosed 1992
Liver biopsy 1998 stage 0-1.
Peg inf + riba 1999, stopped at 25 weeks due to side effects-undetected then but reappeared within 3 months.
Liver biopsy 2006 - stage 0-1.
Fibroscan 2015 - stage 0-1.
VL >12 million.
AST, ALT high normal range.
7/17/15 Started Harvoni for 12 weeks.
8/4/15   VL 70, AST 19, ALT 11
9/17/15 VL Undetected (<12), AST 19, ALT 16
11/10/15 EOT +5 weeks VL Undetected (<12), AST 16, ALT 14
1/12/16 EOT + 14 weeks VL Undetected (<12)
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