Adult Male With A Birth Date Of 11 / 30 / 1964

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A review of the records reveals the member to be an adult male with a birth date of 11/30/1964. The member has a diagnosis of chronic hepatitis C virus, genotype 1a. The member’s treating provider, Steven Zierer, MD has recommended treatment with the prescription medication, Harvoni 90mg – 400mg 1 tab daily for 12 weeks for this member.

The carrier has denied coverage of Harvoni 90mg – 400mg as not medically necessary. There is a letter from the carrier to the member dated 11/20/2015, which states in part:

“Our guideline for sofosbuvir/ledipasvir requires that the patient meet the following criteria: is at least 18 years old; has genotype 1 hepatitis C; is currently supervised by a gastroenterologist, infectious disease specialist,
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This not only puts their medical wellbeing and overall health at unneeded risk as stated previously, but also reduces the likelihood of their future response when therapy would eventually be allowed. None of this is appropriate or supported by national guidelines.”

Final External Review Decision: The carrier’s decision in denying coverage for the requested prescription medication, Harvoni 90mg - 400mg, was appropriate for the treatment of this member’s condition.

The requested prescription medication, Harvoni 90mg - 400mg, would be medically necessary for the treatment of this member’s condition, however, at this time, the member does not meet the medical necessity criteria for coverage due to his continued use of alcohol.

The expected benefit of the recommended or requested health care service or treatment is more likely than not to be beneficial to the claimant than any available standard health care
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