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Post Info TOPIC: DENIAL OF HARVONI - THE DUMMIES GUIDE TO APPEALS!


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DENIAL OF HARVONI - THE DUMMIES GUIDE TO APPEALS!
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Hey All

Having a thread that allows our members to reveal there insurance concerns via copies of there denial information and associated references does two important things.

It allow them a place to vent there personal frustration which is cathartic in its nature and has some benefits to them.

Its also gives insight into the direction that the various insurance companies are taking towards paying for Harvoni.   Its a given that every persons appeal process will be handled somewhat different because of the hundreds of Health insurance companies and everyone's health is situation is different. 

Simple said, we learn from others experience and can gain some benefits from hearing about them. That does not mean they will be without errors and mistaken viewpoints so everyone has the be accountable for their own decisions, not relying on the forum to make it for them. This topic will fizzle out fairly soon but leave a trail to follow like most threads.

The other issue about words reminds me of a proverb

Proverb 12:18 "Thoughtless speech is like the stabs of a sword, But the tongue of the wise is a healing. "   

matt



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"And in the end, the love you take is equal to the love you make"

61 year old Geno type A1, F4 Cirrhotic, started 24 weeks on Harvoni 12-17-14 ,EOT-5 week = UND, 8-31-15 =UND , SVR-24 Baby YES! 



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All sounds so reasonable but think ahead people.  This situation is likely to go on for months, and longer, and it will remain the focus of this forum if you keep it up.   It is all about "me, me, me" getting my tx; it isn't actually about helping others get through this at all.

It will attract more of the same and repel others who are not of that mindset.  Additionally, this type of advice does more harm than good.  Think about it before you jump on board.   Malcolm was right.  This is not something to be proud of or to support.  

 



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Diagnosed in 2011, Incivek triple in 2011, tx discontinued, Genotype 1a, CT, VL 7mill, cirrhosis dx in 2012, age 67, waiting for new DAAs.



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Yes, of course! I think i have been professional and courteous. I just responded to what was said because I want the same thing.

 I am only  here to gather information & support and to share what I learn, that may help others.

Thanks!



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Diagnosed 10/04 / VL 12.7 M / Genotype 1b - Grade 2, Stage 1 / 2007 -Pegylated Interferon & Ribavirin - Stopped Due to Sides / 2011 - Telaprevir, Interferon & Ribavirin - Stopped Due to Sides / APR 2015 - COMPLETED HARVONI So Far Undetectable :) 

Tig


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We are here to support, not to spar. We ask that responses be kept civil and non confrontational. Can we agree to do that? We are all after the same goal, and it will happen in time. Together we conquer and divided we fall (fail). Let's work this out, the benefits are worth the effort!

Tig



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Tig

67yo GT1A - 5 Mil - A2/F3 - (1996) Intron A - Non Responder, (2013) Peg/Riba/Vic SOT:05/23/13 EOT:12/04/13 SVR 9+ years!

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Hey Brownie: and others

first, here is what CDPHP put in my denial

  "Current treatment guidance from the American Association for the Study of Liver Diseases (AASLD) places the highest priority of treatment for hepatitis C among individuals who have fibrosis stages F3, F4, or in some cases of F2 with significant extrahepatic manifestations of chronic hepatitis C disease such as mixed cryoglobulinemia and vasculitis"

I just went to the AASLD website - seems they left a few things out:

"Our recent addition to the Guidance prepared by a committee of leading liver experts from AASLD and The Infectious Diseases Society of America (IDSA) proposed that the sickest patients be treated first, but all patients who receive advice from their doctor to take newest medications should not be denied. The decision across the board should be in the hands of the clinician and the patient to make the decision. Unfortunately payers across America are denying treatment when a doctor has prescribed it for their patient. We adamantly disagree with this decision.

Our Guidance is not intended to be used by payers to deny access to treatment. In no way does this position contradict the evidence evaluated to produce the Guidance and the recommendation made in the Guidance to treat the sickest first, but recognizes need to treat all.

And, they just sent me a copy of the actual denial letter. Get this, a PEDIATRICIAN is the one who reviewed my claim!!!!!!!!!!!!!! WTF is that all about?



-- Edited by shadow10cats on Friday 31st of October 2014 08:21:24 PM

__________________

Diagnosed 10/04 / VL 12.7 M / Genotype 1b - Grade 2, Stage 1 / 2007 -Pegylated Interferon & Ribavirin - Stopped Due to Sides / 2011 - Telaprevir, Interferon & Ribavirin - Stopped Due to Sides / APR 2015 - COMPLETED HARVONI So Far Undetectable :) 



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Hi again, BJ, thanks for clearing up the misunderstanding between `Drs` and `docs`. 

We all understand just how frustrating this situation is for you and many other people at the moment and there is a need for people to be able to discuss it, of course.  I`m quite sure that this can be done without anyone getting personal or resorting to insults though, and I agree that if anyone finds this thread annoying and can`t manage to remain civil then it`s best if they stay off it.  It`s up to the Admin team to say if a thread is inappropriate and no, you haven`t broken any forum rules. 

Let`s all try and be patient with each other and stay calm! 

 

 



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Jill 

(71 yo, lives in UK)

Was Gen 3a, 

24wks Peg Ifn/Riba, Sep 2010 - Mch 2011

UND @ Wk.4, UND @ EOT, 

SVR Nov 2011 --> Still UND @ EOT + 4 yrs.

 

 



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BROWNIE: this is exactly why I started this post.  I will certainly check into what you referred to. 

I don't think it's any secret that insurance companies want people to accept their denials and go away.  That's with any type of claim: auto, home, health.

Do your work,  get your ducks in a row, gather supporting documentation & present your case. 

After all as IsisCat said: Appeals will be handled on a case-by-case basis.  Not sure how she knows that but even more reason to make sure you present the strongest case.



__________________

Diagnosed 10/04 / VL 12.7 M / Genotype 1b - Grade 2, Stage 1 / 2007 -Pegylated Interferon & Ribavirin - Stopped Due to Sides / 2011 - Telaprevir, Interferon & Ribavirin - Stopped Due to Sides / APR 2015 - COMPLETED HARVONI So Far Undetectable :) 



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IsisCat: you are entitled to your opinion. I respectfully disagree. 

If anyone wants to share documentation that supports why Harvoni should be available to those it was intended to treat - you can post it here or private email me. 

If you are not interested in this topic you don't have to participate - go chat somewhere else.  

The last thing anyone needs right now is the HepC Gestapo trying to silent those speaking up for their right to receive this drug. 

It's funny because from what I've seen, you are in the minority.  The "silent" minority.   From what I've seen - and not just here -  is that folks are appealing & working very hard to secure this drug. So seems to me you are barking up the wrong tree!

There's always someone who gets all pissy when they can't control everything - but I question your motivation for trying to keep us from fighting for this drug.  Not that I am suggesting you are a plant of course.  

Lastly, I have never resorted to insulting you so don't try it with me. I am not a child  - I am a very educated adult - The only behaving like a child is you - stomping your feet when someone disagrees with you. I thought initially you had made a mistake in reading my post now I see you are responding exactly as I thought.

So unless I'm breaking some forum rules: I stand by my discussion of sharing info, helping others with writing their appeal & being proactive.

 



__________________

Diagnosed 10/04 / VL 12.7 M / Genotype 1b - Grade 2, Stage 1 / 2007 -Pegylated Interferon & Ribavirin - Stopped Due to Sides / 2011 - Telaprevir, Interferon & Ribavirin - Stopped Due to Sides / APR 2015 - COMPLETED HARVONI So Far Undetectable :) 



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Hi BJ,

After being denied 3 times and then being approved for S/O earlier this year, I requested my files so I could see what all was involved in the process. They had sent a letter saying I was entitled to my records, free of charge, but two requests later I still haven't received them. I'm going to try again bc with me, it seems three times a charm!

If your insurance is basing it on AASLD guidelines, didn't I just see something posted here this week how they changed their stance on who should be treated?

http://hepcfriends.activeboard.com/t58889925/updated-introductory-statement-of-when-and-in-whom-to-initia/

I don't know if it would help, just saying . . .

Best wishes for your quest of treatment!    CJ

 



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I asked CHP for a copy of my denial.  

I also asked them for the guidelines, parameters, etc someone had suggested.  They told me: "they do not have coverage criteria for Harvoni for members with HepC" . Not sure if that means they don't have anything - or - they don't have it for HepC patients.If the first part: they should & if the 2nd part - just who is this for then? Either way sounds like BS.

They are saying they based my denial on AASLD (The American Association for the Study of Liver Diseases)  guidance for treatment saying they place the highest priortiy for treatment on the sickest..." Prioritizing is one thing - Denial is something completely different.

They referred also to a section of their coverage that excludes coverage for services not medically necessary!!!  So they feel my getting Harvoni is not necessary. I will be requesting a copy of this section

Before I was frustrated -- Now I'm really mad



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Diagnosed 10/04 / VL 12.7 M / Genotype 1b - Grade 2, Stage 1 / 2007 -Pegylated Interferon & Ribavirin - Stopped Due to Sides / 2011 - Telaprevir, Interferon & Ribavirin - Stopped Due to Sides / APR 2015 - COMPLETED HARVONI So Far Undetectable :) 



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shadow10cats wrote:

 

 I removed my response to IsisCat because now I think I see what she was referring to. She didn't want us mentioning various Drs.  That's not what I was saying.


I read your post and you wrote substantially more than that.  We might as well put our cards on the table here because you really don't get it.

Appeals will be handled on a case-by-case basis.  People's situations are entirely different: different states, different insurance companies, different policies, different health conditions, different doctors, and on and on.  There is also the Gilead v Insurance Co. war being played out which you seem to think you can control.  What you are suggesting will create chaos here, keep people in a constant state of distress, and provide very little if any help to anyone in the end. 

I'm done playing with children.  Grow up and accept that you may not get what you want the moment you want it. 



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Diagnosed in 2011, Incivek triple in 2011, tx discontinued, Genotype 1a, CT, VL 7mill, cirrhosis dx in 2012, age 67, waiting for new DAAs.



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I don't care about mentioning Drs.  I didn't realize I said that. I am interested in sharing any info that will be helpful as supporting documentation for an appeal.  I think you may have mis-read my abbreviated word for documents (docs) as DRs.  Sorry, not the same thing.  

NOW I THINK I UNDERSTAND: SOME OF YOU MISTOOK docs AS DRS.  DOCS = DOCUMENTS 

 I removed my response to IsisCat because now I think I see what she was referring to. She didn't want us mentioning various Drs.  That's not what I was saying



-- Edited by shadow10cats on Friday 31st of October 2014 06:28:56 PM



-- Edited by shadow10cats on Friday 31st of October 2014 06:31:21 PM

__________________

Diagnosed 10/04 / VL 12.7 M / Genotype 1b - Grade 2, Stage 1 / 2007 -Pegylated Interferon & Ribavirin - Stopped Due to Sides / 2011 - Telaprevir, Interferon & Ribavirin - Stopped Due to Sides / APR 2015 - COMPLETED HARVONI So Far Undetectable :) 



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hopefully the confusion of docs and drs is cleared up 



-- Edited by shadow10cats on Friday 31st of October 2014 06:42:26 PM

__________________

Diagnosed 10/04 / VL 12.7 M / Genotype 1b - Grade 2, Stage 1 / 2007 -Pegylated Interferon & Ribavirin - Stopped Due to Sides / 2011 - Telaprevir, Interferon & Ribavirin - Stopped Due to Sides / APR 2015 - COMPLETED HARVONI So Far Undetectable :) 



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Hi BJ, this will be an interesting topic for many of our members, thanks.  Sharing useful info is always helpful but I agree with Isiscat that naming specific doctors would not be appropriate here.

Wishing you and everyone else who is going through the appeal procedure the very best of luck!  smile

 



__________________

Jill 

(71 yo, lives in UK)

Was Gen 3a, 

24wks Peg Ifn/Riba, Sep 2010 - Mch 2011

UND @ Wk.4, UND @ EOT, 

SVR Nov 2011 --> Still UND @ EOT + 4 yrs.

 

 



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shadow10cats wrote:

______________________________________________________________________________________________________________

What I would like to do with this forum is have us all post various info & docs helpful in the appeal process. 

_____________________________________________________________________________________________________________

This is a very bad idea for this forum, IMO.  

 



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Diagnosed in 2011, Incivek triple in 2011, tx discontinued, Genotype 1a, CT, VL 7mill, cirrhosis dx in 2012, age 67, waiting for new DAAs.



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Hey BJ

Sounds like your gearing up for a interesting battle, just offering some insight but if you have not done so already make sure you contact Gilead Support Path Program because if you follow there protocol for appeal and its gets rejected again then you will received Harvoni at no cost directly from Gilead via your doctor approval with only a few conditional qualifications  on income and verification.

matt 



__________________

"And in the end, the love you take is equal to the love you make"

61 year old Geno type A1, F4 Cirrhotic, started 24 weeks on Harvoni 12-17-14 ,EOT-5 week = UND, 8-31-15 =UND , SVR-24 Baby YES! 



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We are all here for U  . God bless U and help U.



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MDodrow


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I am in the process of appealing the denial of Harvoni from CDPHP (CHP) here in NYS.  I initially thought my Dr did that but unfortunately it's all up to me.  I will need supporting doc from my Drs but I do all the legwork. 

I can guarantee, I won't just be limited to the form there will be several attachments! 

One thing I know is that denials have nothing to do with so called criteria ins are pulling out of their butts.  It IS all about MONEY!  (I am going to look thru my policy and see where it says that CHP can deny me treatment based on price.  Has anyone found that in their policy anywhere?

What I would like to do with this forum is have us all post various info & docs helpful in the appeal process. 

I am starting to gather info & will share as I go. I went online last night and got records of money CHP paid out since 2007 (I was diagnosed in 2004 but online records only go back to 2007) They've paid out almost $200,000 related to this disease (I see they only ended up paying $16,000 for my Telaprevir when it was supposed to be $26,000).  Since 2007 - 2014 the expense has increase each year and went up 187% since 2007! I am in my late 50's & if I have to wait until I am in late stage liver disease gosh knows how much they will continue to pay out each year as this disease progresses & new issue crop up.  Not to mention the loss of a FT salary making over $70k a year due to the symptoms of HepC. 

Anyway if anyone out there is working on their appeal & would like to share info this is the place to do it?

thanks!!!



-- Edited by shadow10cats on Friday 31st of October 2014 04:06:27 PM



-- Edited by shadow10cats on Friday 31st of October 2014 05:01:27 PM

__________________

Diagnosed 10/04 / VL 12.7 M / Genotype 1b - Grade 2, Stage 1 / 2007 -Pegylated Interferon & Ribavirin - Stopped Due to Sides / 2011 - Telaprevir, Interferon & Ribavirin - Stopped Due to Sides / APR 2015 - COMPLETED HARVONI So Far Undetectable :) 

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