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

You asked the Plan to cover Dronabinol. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Dronabinol. The drug is requested to treat chronic pain syndrome in an enrollee with gastroparesis and a feeding tube, which is an off-label (non-FDA approved) use. In a statement dated December 11, 2020 you state the enrollee has been taking the requested medication since December 6, 2019 for the treatment of nausea and vomiting due to gastroparesis with a feeding tube. Medical records from date of service November 18, 2020 were provided which documents that the requested drug is being used for the treatment of chronic pain syndrome. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. A medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia. Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicare approved compendia that support the use of Dronabinol for the diagnosed condition. As a result, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be covered under the Medicare Part D benefit for this condition. An exceptions request based on medical necessity cannot be considered because this drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage for Dronabinol.This decision does not concern the medical necessity of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Sandostatin LAR. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Sandostatin.Sandostatin is requested for treatment of Osler- Weber Rendu/hereditary hemorrhagic telangiectasia associated with recurrent angioectasias which is an off-label (non-FDA approved) use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. You have outlined the enrollee's clinical history and have discussed the rationale for prescribing the noted drug. Additionally, you have submitted medical literature to support the request for Sandostatin LAR to treat the noted condition; however the Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. A medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia. Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicare approved compendia that support the use of Sandostatin LAR for the diagnosed condition. As a result, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be covered under the Medicare Part D benefit for this condition. An exceptions request based on medical necessity cannot be considered because this drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage for Sandostatin LAR.This decision does not concern the medical necessity of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Acetaminophen-Codeine 300-30 mg tablet, 200 tablets per 25 days. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Acetaminophen-Codeine 300-30 mg tablet, 200 tablets per 25 days. Acetaminophen-Codeine300-30 mg tablet, 200 tablets per 25 days is requested for ongoing treatment of chronic back/neck pain. You state that the enrollee has taken the requested medication for over six years to control pain, and that enrollee needs to continue the requested medication. The enrollee satisfies the Plan's coverage criteria. Our Physician Reviewer's opinion is that prior authorization criteria are met. A quantity limit exception is also being requested. The Plan's quantity limit for Acetaminophen-Codeine 300-30 mg tablet is 180 tablets per 30 days. The medication record supplied indicates that the enrollee was previously treated with lower total daily doses of the requested drug, and as noted, you have indicated that the requested drug needs to be continued to control the enrollee's pain. The documentation indicates that the enrollee has previously failed the quantity of Acetaminophen-Codeine 300-30 mg tablet allowed by the Plan; therefore an exception to the Plan's quantity limit is warranted. Our Physician Reviewer's opinion is that quantity limit exception has met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. Based on the available documentation, our Physician Reviewer's opinion is that prior approval criteria are met. Therefore, our decision is the Plan is required to cover Acetaminophen-Codeine 300-30 mg tablet, 200 tablets per 25 days.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Eliquis for plan year 2021. The Plan did not grant this request. We received this case to conduct an independent review.Medicare rules do not require the Part D plan to grant a tiering exception for a brand or biologic drug of the same type if the lower tier(s) on the formulary only contain(s) generic alternative drugs. Eliquis is a Tier 3 brand drug. The lower cost-sharing tier(s) only contain(s) generic alternative drugs. Therefore, our decision is the Plan is not required to provide a tiering exception for Eliquis.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Ninlarco. The Plan did not grant this request. We received this case to conduct an independent review.We asked a Physician Reviewer to determine whether the Plan was correct in denying the request for Ninlarco which is subject to prior approval. Our Physician Reviewer needed additional information from you to make this determination. You were asked to address whether the drugs offered by the Plan for the treatment of the enrollee's condition would: (1) not be as effective as the requested drug; and/or (2) have adverse effects. The requested information was not received. Based on a review of the available documentation, neither prior authorization criteria nor prior authorization exception criteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. A Plan must grant an exception to prior approval rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on the available documentation, our Physician Reviewer's opinion is that an exception to prior approval criteria is not met. Therefore, the Plan is not required to cover Ninlarco.
Appeal type: Prescription Drug
Decision: Unfavorable

We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Esomeprazole Magnesium DR 40 mg capsule (180/90 or 60/30).We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Esomeprazole Magnesium DR 40 mg capsule (180/90 or 60/30). Esomeprazole Magnesium DR is requested to treat chronic gastroesophageal reflux disease (GERD) and Barrett's esophagus. Upon the reopening request, the prescriber statement was returned. You documented that the requested drug was started on May 13, 2014. Step therapy applies to new starts only. Per HPMS (Health Plan Management System - CMS's official database for Plan formularies), the plan's coverage rules apply to new starts only. The enrollee is already taking the requested drug; the requested drug is not a new start.The Plan limits the amount of Esomeprazole Magnesium DR 40 mg tablet to 30 tablets per 30 days. You documented that the enrollee has had a failure of Esomeprazole DR 40 once daily. Per DRUGDEX, the monograph in the non-FDA use section under the discussion of Gastroesophageal reflux disease, Refractory - Twice-daily dosing of proton pump inhibitors (PPIs) is recommended to improve symptom relief in patients with refractory GERD. You have indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the enrollee's condition, and/or would likely cause harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is medically necessary.Our Physician Reviewer's opinion is that quantity limit exception criteria are met.We previously requested additional information from the prescriber to determine whether the Plan's step-therapy criteria for Esomeprazole Magnesium DR 40 mg capsule (180 per 90 days or 60 per 30 days) were satisfied. We did not receive the information from the prescriber. As a result, we issued an unfavorable reconsideration decision. We subsequently received the additional information previously requested from the prescriber. We reopened this appeal to conduct a second review with the additional information.Medicare rules allow a Part D Plan to manage its formulary by covering a limited quantity of certain drugs. A Plan must grant an exception if it determines that the requested dosage is medically reasonable and necessary, consistent with the prescriber's statement. Based on a review of the available documentation, our Physician Reviewer's opinion is that an exception to the quantity limit criteria is met. Therefore, the Plan is required to cover the requested quantity of Esomeprazole Magnesium DR 40 mg capsule (180 per 90 days or 60 per 30 days).This decision reverses our previous unfavorable decision.
Appeal type: Prescription Drug
Decision: Unfavorable

We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Dupixent 300 mg/2 ml Pen. Dupixent 300 mg/2 ml Pen is requested to treat unspecified atopic dermatitis (ICD-10 L20.9. Upon reopening of this case, additional information was submitted by you, your letter documented that the enrollee was using topical Tacrolimus on November 3, 2020. However, you did not document/confirm that the enrollee had tried the required Tacrolimus ointment for at least 30 days. The enrollee does not satisfy the Plan's coverage criteria. You have not sufficiently addressed the Plan's coverage criteria and/or have not indicated why all alternatives required by the Plan would likely not be as effective for the enrollee as the requested drug, and/or would likely cause adverse reaction(s) or other harm to the enrollee. Our Physician's opinion is that neither prior authorization nor prior authorization exception criteria are met.We previously issued an unfavorable reconsideration decision, finding that the Plan was not required to provide coverage of Dupixent. Our Physician Reviewer determined that prior authorization criteria was not met. After we issued our decision, we received new information. We reopened this appeal to conduct a second review.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. A Plan must grant an exception to prior approval rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on the available documentation, our Physician Reviewer's opinion is that an exception to prior approval criteria is not met. Therefore, the Plan is not required to cover Dupixent.This decision affirms our previous unfavorable decision.
Appeal type: Prescription Drug
Decision: Unfavorable

We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Corlanor 7.5 mg tablet. Corlanor 7.5 mg tablet is requested for ongoing treatment of a 46 year old male with non-ischemic cardiomyopathy/chronic systolic heart failure with an ejection fraction (EF) of 17%, a heart rate of at least 70 beats per minute on maximally tolerated beta-blocker doses, status post (s/p) supraventricular tachycardia (SVT) ablation and s/p biventricular pacemaker (heart rate NOT exclusively maintained by pacer; functionally pacing 9% of time). Upon the reopening request, you submitted additional/new information. The enrollee satisfies the Plan's coverage criteria. Our Physician Reviewer's opinion is that prior authorization criteria are met.We previously issued an unfavorable reconsideration decision, finding that the Plan was not required to provide coverage of Corlanor. Our Physician Reviewer determined that prior authorization criteria was not met. After we issued our decision, we received new information. We reopened this appeal to conduct a second review.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. Based on the available documentation, our Physician Reviewer's opinion is that prior approval criteria are met. Therefore, our decision is the Plan is required to cover Corlanor.This decision reverses our previous unfavorable decision.
Appeal type: Prescription Drug
Decision: Unfavorable

case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Zyprexa.Zyprexa is requested for treatment of behavioral problems associated with the following diagnoses: autism spectrum disorder, static encephalopathy, global developmental delay, mood lability, generalized anxiety with obsessive-compulsive disorder, and a receptive and expressive language disorder, which are off-label (non-FDA approved) uses for the requested drug. The prescriber has detailed the enrollee's clinical history including the significant danger the enrollee poses to himself and others, and the improvement with Zyprexa; however the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. A medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia. Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicare approved compendia that support the use of Zyprexa, 5 mg tablet for the diagnosed condition. As a result, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be covered under the Medicare Part D benefit for this condition. An exceptions request based on medical necessity cannot be considered because this drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage for Zyprexa, 5 mg tablet.This decision does not concern the medical necessity of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Aspirin EC. The Plan did not grant this request. We received this case to conduct an independent review.Medicare Part D does not cover non-prescription drugs. We checked FDA approved sources for the drug's classification or determined from other available resources that the drug is a non-prescription or OTC drug. Therefore, Aspirin EC is not eligible for Part D coverage, and the Plan is not required to cover it under the Part D benefit. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide reimbursement for Hydroxychloroquine 200 mg purchased August 4, 2020. The Plan did not grant this request. We received this case to conduct an independent review.Medicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. 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 Plan required a $36 for up to a 90 day supply of a Tier 2 drug purchased in 2020 from a standard retail pharmacy. Hydroxychloroquine 200 mg is on the Plan's 2020 formulary and classified as a Tier 2 drug. A request for reimbursement was submitted to the Plan. In this case, the Plan provided documentation showing that this claim was covered by the Plan at the time of purchase. The record shows that Hydroxychloroquine 200 mg purchased August 4, 2020 was purchased for an amount that is less than or equal to the required copayment amount. The case record indicates that the Plan provided coverage in accordance with the Part D contract. Therefore, our decision is the Plan is not required to provide reimbursement for Hydroxychloroquine 200 mg purchased August 4, 2020.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Lidocaine 5% Patch. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Lidocaine 5% PatchLidocaine 5% Patch is requested to treat low back pain. For coverage under the prescription drug benefit, Medicare requires that the drug prescribed be used for a medically accepted indication. DRUGDEX, a Medicare approved compendium, has listed chronic back pain, hip or knee osteoarthritis pain in their Comparative Efficacy section in the monograph for the requested drug which includes a link to the following article: Krebs EE, Gravely A, Nugent S, et al: Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial. JAMA 2018; 319(9):872-882. PubMed Abstract: http://www.ncbi.nlm.nih.gov/... PubMed Article: http://www.ncbi.nlm.nih.gov/... The article states, Among patients with chronic back pain or hip or knee osteoarthritis pain, treatment with opioids compared with nonopioid medications did not result in significantly better pain related functionover 12 months. Non-opioid treatment was associated with significantly better pain intensity. (i.e. less pain) Our Physician Reviewer found that the Medicare-approved resources do contain citations to support the use of the requested drug for treatment of the noted condition. Therefore, the requested drug is being prescribed for a medically accepted indication. You do not satisfy the Plan's coverage criteria. The prescriber has indicated why all alternatives required by the Plan would likely not be as effective as the requested drug for you, and/or would likely cause adverse reaction(s) or other harm to you. Therefore, an exception to the Plan's coverage criteria is medically necessary. Our Physician Reviewer's opinion is that prior authorization exception criteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. A Plan must grant an exception to prior approval rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on the available documentation, our Physician Reviewer's opinion is that an exception to prior approval criteria is met. Therefore, our decision is the Plan is required to cover Lidocaine 5% Patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Actemra 162 mg/0.9 mL. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Actemra.Actemra is requested for treatment non-infectious uveitis, which is an off-label (non-FDA approved) use. The prescriber states that the enrollee has a vision threatening condition which has not responded to all standard of care medications, and he has submitted some supportive medical references; however the Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. A medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia. Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicare approved compendia that support the use of Actemra 162 mg/0.9 mL for the diagnosed condition. As a result, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be covered under the Medicare Part D benefit for this condition. An exceptions request based on medical necessity cannot be considered because this drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage for Actemra 162 mg/0.9 mL. This decision does not concern the medical necessity of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.