Yesterday, Austin flagged two lawsuits that have been filed in California against Anthem Blue Cross over its refusal to pay for Harvoni to treat Hepatitis C. Setting aside the question of whether Harvoni is cost-effective—check out Allan Joseph on that—what are the lawsuits about? And are they likely to succeed?
Anthem denied Harvoni to the plaintiff in the lead California case on the ground that it wasn’t medically necessary for someone with her limited extent of liver damage. The rejection appears to be inconsistent with prominent clinical guidelines, which say that some kind of therapy should be provided to anyone with Hep C, although priority should be given to those with serious liver damage. The American Association for the Study of Liver Disease, for example, has said that successful treatment “is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons.”
Nonetheless, Anthem refused to pay for Harvoni based on its own internal guidelines, which you can see here. (I have no idea what resources Anthem used to develop its guidelines; the guidelines themselves don’t say.) Although Harvoni is only one of three recommended therapies for someone with the plaintiff’s type of Hep C, it doesn’t look like Anthem would have paid for the two alternatives either.
Judging from the Wall Street Journal article about the lawsuit, Anthem thinks that Harvoni is still experimental for those Hep C patients with healthy-ish livers. As an Anthem spokesperson explained, “[b]roader use of these drugs and knowledge about the long term effects and potential harms and outcome of various alternative therapies are needed on those with limited effects of infection.”
I’m hesitant to draw strong conclusions without hearing more fully from Anthem, but this strikes me as a weak defense. Anthem is contractually bound to cover medically necessary care. Even if it’s reasonable in the abstract to think that some Hep C patients might not benefit from Harvoni, Anthem’s position appears to be, in the words of one California court, “significantly at variance with the medical standards of the community.” And if there’s anything clear in the law, it’s that an insurer’s idiosyncratic view of medical necessity is unlikely to carry the day.