Diagnosis: Hepatitis C

Treatment: Epclusa

The insurer denied coverage for Epclusa. The denial was upheld.

This patient is a female with chronic disease of the liver, hypothyroidism, and asthma. The patient presented for follow-up. She denied symptoms at the time and decided to start management of the disease in early-2019. The provider discussed the possibility of starting medication management sooner.

The American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of American (IDSA) has issued guidelines for the treatment of hepatitis C genotype 1a without cirrhosis. Both Epclusa and Mavyret are recommended regimens. Mavyret is only recommended for 8 weeks of treatment while the duration of Epclusa treatment is 12 weeks. The SVR [Sustained Virologic Response] rate for Mavyret was 99%. The preferred product offered by the insurance company was Mavyret. It has a success rate of 99% and an excellent safety profile. It is considered appropriate treatment for this patient. Therefore, Epclusa is not medically necessary. There are no contraindications to the patient taking Mavyret. There is no record of intolerance to Mavyret. The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient. The denial of Epclusa is upheld.

The carrier's denial of coverage for Epclusa is upheld. The medical necessity is not substantiated.