Persius/hicric huggingface dataset:
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Krazati 200 milligram tablet to treat colon cancer. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Procrit 20,000 units per milliliter injection to treat anemia associated with chronic kidney disease, stage 4. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. Furthermore, the documentation does not support the medical necessity for an exception to the plans prior authorization requirements.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Lokelma 10 gram powder packet to treat hyperkalemia. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The requested drug is not on the plans formulary. To grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed or must be deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale as to why the alternative drugs on the plans formulary to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Additionally, the submitted documentation does not support that the enrollee has tried and failed all of the formulary alternative drugs. Therefore, the formulary exception requirements have not been met.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Rexulti 1 milligram tablet to treat anxiety and depression. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. Furthermore, the documentation does not support the medical necessity for an exception to the plans prior authorization requirements.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Dextroamphetamine/Amphetamine 20 milligram extended release capsule to treat hypersomnia. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Mesalamine 1.2 gram tablet to treat collagenous colitis. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Zolpidem 10 milligram tablet to treat insomnia. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. Furthermore, the documentation does not support the medical necessity for an exception to the plans prior authorization requirements. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is coverage for Everolimus 5 milligram tablet to treat recurrent meningioma of left orbit. The Part D plan denied the request for coverage because the drug was going to be used as single-agent therapy to treat the enrollees condition.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation submitted.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. At reconsideration, the prescriber has clarified that the requested drug will be given in combination with Avastin (Bevacizumab) to treat the enrollees condition. As outlined in the National Comprehensive Cancer Network (NCCN) guidelines (a Medicare approved compendium), Everolimus is indicated in combination with Avastin (Bevacizumab) for surgically inaccessible recurrent or progressive disease when radiation is not possible for meningioma. The medical records show that the enrollee meets this indication. Therefore, the drug is being prescribed for a medically accepted indication outlined in the NCCN guidelines. In addition, since the drug is being used for a medically accepted indication outlined in the NCCN guidelines, an exception to the plans prior authorization requirements is supported. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Xarelto 20 milligram tablet to treat the enrollee's condition. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Xarelto 20 milligram table is a brand drug on Tier 2 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this drug is not eligible for a tiering exception.A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Hydromorphone 4 milligram tablet to treat unknown diagnosis. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Hydromorphone is a generic drug on Tier 3 of the plans formulary. The prescriber has not provided patient-specific clinical rationale as to why all of the lower-tiered alternative drugs on the plans formulary to treat the enrollees condition are contraindicated. Therefore, the tiering exception requirements have not been met. A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Esomeprazole Magnesium 40 milligram delayed release capsule. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The submitted documentation does not include medical records or evidence of a prescribed diagnosis. This information was requested by the Part D plan with no response from the prescriber/prescribers office. During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to determine what the condition is that requires treatment with the requested drug. However, the prescriber did not respond to our request. As such, there is insufficient documentation available to establish that the requested drug has been prescribed for a medically accepted indication.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Rytary 195 capsule. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.During this review, we requested additional information from the prescriber. Specifically, we requested a medically accepted indication, medical records, and a prescriber statement to support that all formulary alternatives were tried and failed or were deemed contraindicated. However, the prescriber did not respond to our request.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The submitted documentation to the plan does not include medical records or evidence of a prescribed diagnosis. The documentation submitted at reconsideration also does not include medical records or evidence of a prescribed diagnosis. As such, there is insufficient documentation available to establish that the requested drug has been prescribed for a medically accepted indication.Additionally, the requested drug is not on the plans formulary. Even if a medically accepted indication was given by prescriber, in order to grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed or must be deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale as to why the alternative drugs on the plans formulary to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm, as requested. Therefore, the formulary exception requirements have not been met.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: At-Risk Determination
Decision: Unfavorable

A reconsideration request was auto-forwarded from the plan to review the at-risk determination. The plan has imposed a restriction on opioids for the enrollee. The enrollee cannot exceed 90 morphine milligram equivalent (MME) dosage per day.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The records show the plan imposed a restriction on the enrollee. The enrollee cannot exceed 90 morphine milligram equivalent (MME) dosage per day. The drug at issue would exceed this restriction. There was no documentation from the prescriber to support exceeding the plan's restriction.A physician reviewed the appeal and determined the plans restriction is appropriate as there is a risk of obtaining an unsafe quantity of frequently abused drugs (i.e., opioids and benzodiazepines) when receiving prescriptions from multiple prescribers.In conclusion, the decision of the QIC is unfavorable.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a reimbursement request for Heplisav- B vaccine. The Part D plan denied the request.We received a case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan's Evidence of Coverage states, if an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The submitted documentation does not include a valid proof of purchase for the drug at issue. Therefore, the request for reimbursement cannot be granted.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metoprolol Succinate Extended Release 25 milligram 24-hour tablet for unknown diagnosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows the enrollee received a 60-day supply of the requested drug on March 1, 2023. This request for payment cannot be approved. This is based on Medicare rules for Reimbursement Requests. The plan's records show this claim was correctly processed by your pharmacy using your Medicare Part D plan as explained in your Evidence of Coverage (EOC) for prescription drugs. This was paid and now is a duplicate claim submission. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Sodium Sulfate, Potassium Sulfate and Magnesium Sulfate 17.5/3.13/gram solution for a colonoscopy preparation. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The requested drug is not on the plans formulary. To grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed or must be deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale as to why the alternative drugs on the plans formulary to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Additionally, the submitted documentation does not support or indicate that the enrollee has tried and failed all of the formulary alternative drugs. Therefore, the formulary exception requirements have not been met.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Mounjaro 5 milligrams per 0.5 milliliter pen injector to treat type 2 diabetes with hyperglycemia. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Mounjaro is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Nexlizet 180-10 milligram tablet to treat hyperlipidemia. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. The requested drug is not on the plans formulary. To grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed or must be deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale as to why the alternative drugs on the plans formulary to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Additionally, the submitted documentation does not support that the enrollee has tried and failed all of the formulary alternative drugs. Therefore, the formulary exception requirements have not been met. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Propafenone Hydrochloride 150 milligram tablet to treat atrial fibrillation. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Propafenone Hydrochloride is a generic drug on Tier 3 of the plans formulary. The prescriber has not provided patient-specific clinical rationale as to why all of the lower-tiered alternative drugs on the plans formulary to treat the enrollees condition are contraindicated. Therefore, the tiering exception requirements have not been met. A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Hydroxychloroquine Sulfate 200 milligram tablet to treat the enrollees condition. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Hydroxychloroquine Sulfate is a generic drug on Tier 3 of the plans formulary. There are no generic drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Myrbetriq 50 milligram tablet ER (extended release) 24 hour to treat the enrollees condition. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Myrbetriq is a brand on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Restasis 0.05 percent droperette to treat dry eye syndrome. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Restasis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for an OptiChamber Diamond Valved Holding Chamber (VHC). The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The requested item is classified by the Food and Drug Administration (FDA) as a medical device. Medical devices do not meet the definition of a Medicare Part D drug and are excluded from Part D coverage. Therefore, the requested item is excluded from Medicare Part D coverage. This decision does not address the medical necessity of the device. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Favorable

At issue is coverage for Balversa 4 milligram tablet to treat metastatic urothelial carcinoma. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The plan has prior authorization requirements for this drug that the enrollee must meet before coverage will be provided. The submitted documentation supports that all of the plans requirements for coverage have been satisfied. Specifically, the prescriber submitted records that indicate metastatic bladder cancer. The member is diagnosed with advanced metastatic urothelial carcinoma with persistent thickening of the bladder, and progress notes state this is stage 4. In addition, the patient was treated with Avelumab, which is indicated for advanced bladder cancer. The member has an identification of a susceptible FGFR3 or FGFR2 genetic alteration as well as FGFR fusions documented in the medical records. The member will use Balversa (Erdafitinib) as a single agent for subsequent therapy after disease progression during or following at least one prior line of platinum-containing systemic chemotherapy. Therefore, the plans prior authorization requirements have been met, and coverage for the drug is supported.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Rhopressa 0.02 percent ophthalmic solution to treat glaucoma. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Rhopressa is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.