Denial of Treatment AGAIN !!

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 biospsy 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 thier 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

ppm guy said...
hi tmf12
hello again.. I had to catch up on HCV for a few minutes. I read the retreatment guidelines for harvoni failures...epclusa is a combo of Sovaldi and velpatasvir. Wikipedia lists velpatasvir as a ns5a inhibitor.
That could be the reason for your denial.

Hopefully your dr will file appeal after appeal.. that used to be the method to gain approval. I read that havoni for 12 weeks with a positive RAV test was 60%... I would think that 24 weeks of epclusa, maybe with riba, could get yu over the hump.. let me know whats up!!!

It is indeed the basis for denial ! Unfortunately I believe all the Hep C meds are in part a NS5A inhibitor which leaves me untreated with Stage 4 Cirrhosis. Has anybody had positive results with a IRO (Independent Review Organization) ?

Dennis

tmf12

my partner, Mike, was Riba/Interferon Intolerant. He was transplanted in 2011 but still had the Hep C. When the new drugs started to be approved he went on Sovaldi and Olysio for the reasons posted above. He went the 12 weeks, was clear week 4, and has been clear since May 2014. We are uncertain how much damage his Hep C did to the transplanted liver so they check him all the time...his LFTs are pretty much perfect...pop up and down a bit, but he is feeling fine. He has had some kidney issues which is not unusualy post TP. Everything has a cost and the anti-rejection meds are tough on kidneys as are some of the heart meds (he had an aortic valve replacement in 2014 also!) But he plays golf some and enjoying his changed life.

Good luck with all this. We have been down the approval process time after time. PPM guy is very knowledgeable. Have you contacted the manufacturer of the meds...they have some programs that are very helpful for the uninsured or under insured.

I wish the Insurance companies would think in terms of the long run...getting the cure will sure cost them a lot less than a protracted final illness or a liver transplant!!!!!

Good luck,

Mama Lama

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 .


Dennis