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Author Topic: External Review Success!  (Read 9172 times)

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Offline Coach Mike

  • Member
  • Posts: 292
    • Affordable Hepatitis C Treatment
External Review Success!
« on: November 10, 2015, 07:13:27 pm »
Hello All,
After three denials for three presriptions, I took the appeals process for the last Harvoni script all the way to to external review stage-the final word on approval or denial of treatment coverage. The whole process took 3 1/2 months of appeals, but today I got the letter. I WAS WRONGLY DENIED treatment by my insurer based on their failure to consider my extra hepatic manifestations, as stated under the criteria for treatment under my plan. I had to file an FOI request to simply see a copy of the criteria. Luckily, (or unluckily) my insurance is through the state, so they had to honor my request.
I could not have negotiated the convoluted process without the help of the Patient Advocate Foundation and my PAF advocate, Brendan Bietry.
My final remark: Do not take your external review rights,guaranteed by the Affordable Care Act, lightly! Exercise that right!
It worked for me!
Thanks again Brendan!
You are the man!
Mike
Genotype 1a, Biopsy:11/2014: F-1, Tx Naive
Fibrosure, 7/20/15: F-1-2
Pre tx v/l: 1,600,000, ALT: 75, AST: 48
Started generic sofosbuvir & ledipasvir: 10/23/15
4 wk labs: 11/19/15, ALT: 21, AST: 16, V/L:  UND
Started 8 week Harvoni tx: 11/20/15
8 wk labs, 12/15/15, ALT: 15, AST: 13, V/L: UND
4/11/16 12 week EOT-Undetected
7/5/16 SVR 24

Offline MaryC

  • Member
  • Posts: 117
  • Life is not a sprint; it's a marathon.
Re: External Review Success!
« Reply #1 on: November 12, 2015, 07:02:41 am »
Hello All,
After three denials for three presriptions, I took the appeals process for the last Harvoni script all the way to to external review stage-the final word on approval or denial of treatment coverage. The whole process took 3 1/2 months of appeals, but today I got the letter. I WAS WRONGLY DENIED treatment by my insurer based on their failure to consider my extra hepatic manifestations, as stated under the criteria for treatment under my plan. I had to file an FOI request to simply see a copy of the criteria. Luckily, (or unluckily) my insurance is through the state, so they had to honor my request.
I could not have negotiated the convoluted process without the help of the Patient Advocate Foundation and my PAF advocate, Brendan Bietry.
My final remark: Do not take your external review rights,guaranteed by the Affordable Care Act, lightly! Exercise that right!
It worked for me!
Thanks again Brendan!
You are the man!
Mike

Awesome perseverance Coach Mike!  Great news!  Sounds like your Advocate was very instrumental in this process! 

Mary
GT 3a
Dx'd 4/15 not known when contracted
Labs 7/15:
-VL 537,000
-AST 32
-ALT 41
-Fibrosis score 0.46 (F1-F2)
Started tx 9/17/2015 with Daklinza + Sovaldi
6/6/16: 24 week EOT SVR!  Cured!

Offline Coach Mike

  • Member
  • Posts: 292
    • Affordable Hepatitis C Treatment
Re: External Review Success!
« Reply #2 on: November 12, 2015, 02:10:44 pm »
My most recent correspondence with my advocate.  Again, he is VERY good at what he does!

Thanks so much --- we have some professional contacts at HepMag as well --- keep doing such amazing work - let's hope that your case and others will provide evidentiary testament to the need for coverage for those with lower fibrosis scoring.

Brendan Bietry
Case Manager, Clinical Team
Patient Advocate Foundation
P.O. Box 635158
San Diego, CA 92163
(800) 532-5274 ext. 2110
(757) 528-4790 efax
brendan.bietry@patientadvocate.org
www.patientadvocate.org
Genotype 1a, Biopsy:11/2014: F-1, Tx Naive
Fibrosure, 7/20/15: F-1-2
Pre tx v/l: 1,600,000, ALT: 75, AST: 48
Started generic sofosbuvir & ledipasvir: 10/23/15
4 wk labs: 11/19/15, ALT: 21, AST: 16, V/L:  UND
Started 8 week Harvoni tx: 11/20/15
8 wk labs, 12/15/15, ALT: 15, AST: 13, V/L: UND
4/11/16 12 week EOT-Undetected
7/5/16 SVR 24

Offline Coach Mike

  • Member
  • Posts: 292
    • Affordable Hepatitis C Treatment
Re: External Review Success!
« Reply #3 on: November 18, 2015, 06:36:38 am »
Got the meds!
Genotype 1a, Biopsy:11/2014: F-1, Tx Naive
Fibrosure, 7/20/15: F-1-2
Pre tx v/l: 1,600,000, ALT: 75, AST: 48
Started generic sofosbuvir & ledipasvir: 10/23/15
4 wk labs: 11/19/15, ALT: 21, AST: 16, V/L:  UND
Started 8 week Harvoni tx: 11/20/15
8 wk labs, 12/15/15, ALT: 15, AST: 13, V/L: UND
4/11/16 12 week EOT-Undetected
7/5/16 SVR 24

Offline gnatcatcher

  • Member
  • Posts: 1,372
Re: External Review Success!
« Reply #4 on: November 18, 2015, 08:44:45 am »
TOUCHDOWN! Great teamwork with Brendan of PAF against a foe that plays dirty.

Gnatty
9/29/71 transfusions
HCV genotype 1a
7/09/15-9/30/15 Harvoni

Before treatment:
Viral Load 9,490,582
FibroScan 19.5 kPa [F4]
ALT 262
AST 217
ALP 183

Most recent:
VL still UNDETECTED (SVR 102)
FibroScan 7.6 kPa [F1-2]
ALT 15
AST 20
ALP 85

Offline Coach Mike

  • Member
  • Posts: 292
    • Affordable Hepatitis C Treatment
Re: External Review Success!
« Reply #5 on: November 18, 2015, 09:48:32 am »
The specialty pharmacy folks said the ONLY people my insurance company had approved were on the liver transplant list-until me.
External Review-use it
EHMs-document them meticulously. See your PCP about everything
Evidence-gather all the scientific data you can
Doctor's Letterr-vital
Advocate Cover Letter-Very, very important they see someone is fighting for you
Your Letter-Make a good one.  If you can't express your situation well in words, get someone who can.
Insurance Company's Criteria for HCV Treatment-Know it by heart.

If all else fails, go to fixhepc, get an online appointment with Dr. Freeman and go on a vacation to Tasmania.
The plane ticket will cost more than everything else combined.
Plus, its summer down there.
Get Well.
Coach Mike
Genotype 1a, Biopsy:11/2014: F-1, Tx Naive
Fibrosure, 7/20/15: F-1-2
Pre tx v/l: 1,600,000, ALT: 75, AST: 48
Started generic sofosbuvir & ledipasvir: 10/23/15
4 wk labs: 11/19/15, ALT: 21, AST: 16, V/L:  UND
Started 8 week Harvoni tx: 11/20/15
8 wk labs, 12/15/15, ALT: 15, AST: 13, V/L: UND
4/11/16 12 week EOT-Undetected
7/5/16 SVR 24

 


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