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

At issue is Rybelsus 7 milligram tablet, 60 tablets per 30 days, to treat type 2 diabetes mellitus. The Part D plan auto-forwarded the request. We received the case to perform an independent and de novo review. To make our decision, we read the 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 plan limits the amount of Rybelsus 7 milligram tablet to 30 tablets per 30 days. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the diagnosis or would be likely to cause harm. Therefore, an exception to the plans coverage criteria is not supported. Please also note that the plan has approved Rybelsus 7 milligram and 14 milligram tablets, each at a quantity limit of 30 tablets per 30 days.  A physician reviewed the appeal and determined that the requested drug, Rybelsus 7 milligram tablet, 60 tablets per 30 days, is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ubrelvy 100 milligram tablets to treat chronic migraine without aura, not intractable, without status migrainosus. 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. The use of the requested drug to treat the provided diagnosis 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 diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D. Furthermore the prior authorization criteria will not be met due to off-label use. Additionally, the quantity limits request for will not be met due to off-label use of the medication. 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 Humira Citrate Free (CF) 40 milligram per 0.4 milliliter subcutaneous pen kit to treat seronegative inflammatory arthritis. The Part D plan denied the At issue is Humira Citrate Free (CF) 40 milligram per 0.4 milliliter subcutaneous pen kit to treat seronegative inflammatory arthritis. 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. In the reconsideration appeal, the prescriber stated that the enrollee has a new diagnosis of psoriatic arthritis. The provided medical records list the diagnosis as inflammatory arthritis. The prescriber stated in the record, that in the absence of psoriasis, psoriatic arthritis can not be definitively diagnosed. The use of the requested drug to treat the provided diagnosis 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 diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D. 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 Androderm 4 milligram per 24 hour patch to treat male hypogonadism in an enrollee with panhypopituitarism and a history of craniopharyngioma. 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. The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria. 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 Humira injector 40 milligrams per 0.4 milliliters to treat sarcoid arthropathy. 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. The use of the requested drug to treat the provided diagnosis 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 diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D. 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 Ofev 100 milligram capsules to treat interstitial lung disease. 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. The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria. 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 Fluoxetine hydrochloride 20 milligram tablets prescribed for anxiety disorder, unspecified. 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. The use of the requested drug to treat the provided diagnosis 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 diagnosis. Therefore, the requested drug is not eligible for coverage under Medicare Part D. This decision does not speak to the medical necessity of this drug; it speaks to whether the Part D drug plan is responsible for payment under the Centers for Medicare and Medicaid Services (CMS) rules. 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 Repaglinide 1 milligram tablet prescribed 540 tablets for 90 days to treat type 2 diabetes. The case was auto-forwarded by the plan. We received the case to perform an independent and de novo review. To make our decision, we read the 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 plan limits the amount of Repaglinide to 120 tablets per 30 days. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the diagnosis or would be likely to cause harm. Therefore, an exception to the plans coverage criteria is not supported. 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 Oxycodone Hydrochloride 5 milligram tablets, 30 tablets per 3 days to treat acute surgical pain. 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 the 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 plan limits the amount of Oxycodone Hydrochloride 5 milligram tablets to 180 tablets per 30 days. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the diagnosis or would be likely to cause harm. Therefore, an exception to the plans coverage criteria is not supported.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 Flomax 0.4 milligram oral capsule 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.Flomax is a brand drug on Tier 3 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: Favorable

At issue is Aubagio 14 milligram tablets to treat relapsing and remitting multiple sclerosis. 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.The drug at issue is not on the plans formulary. The prescriber provided patient specific clinical rationale supported by documentation, indicating why the formulary alternatives, required by the plan, would likely not be as effective as the requested drug for this diagnosis, and/or would likely cause adverse reaction(s) or other harm. Specifically, the prescriber statement and/or medical records indicate the enrollee has previously trialed and failed therapy with Betaseron. Therefore, an exception to the plans formulary coverage criteria is medically necessary.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 Idhifa 100 milligram tablets to treat metastatic cholangiocarcinoma, Isocitrate Dehydrogenase-2 mutation. 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. Medicare-approved compendia do not contain any citations to support the use of the requested drug as prescribed, for treatment of the noted diagnosis. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.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 Cresemba 186 milligram capsules for prophylaxis against invasive fungal infections due to a prolonged regimen of Revlimid/Rituxan/Ibrutinib for diffuse large B cell lymphoma. 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. The use of the requested drug to treat the provided diagnosis 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 diagnosis. Although the Medicare-approved compendia, Lexicomp, lists the use of Cresemba for fungus prophylaxis as a Category C recommendation, Medicare will not accept this designation. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D.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 Aciphex 20 milligram delayed-release (DR) tablet to treat gastroesophageal reflux disease with esophagitis. 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 documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.The requested drug is not on the plans formulary. To grant an exception for a drug not that is not on the plans formulary, alternative formulary drugs must have been tried and failed, or deemed contraindicated. At reconsideration, it has been noted that the enrollee tried and failed the generic equivalent of the requested drug and had worsening symptoms. However, there is no indication in the submitted progress notes from physician office visits dated July 22, 2021, and October 3, 2022, that the enrollee has tried anything other than the requested drug, Aciphex. As such, there is insufficient documentation to support a formulary exception in this case.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 Dronabinol 2.5 milligram capsule prescribed for nausea and vomiting post liver transplant, with severe protein-calorie malnutrition. 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. The use of the requested drug to treat the provided diagnosis 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 diagnosis. Therefore, the requested drug is not eligible for coverage under Medicare Part D. This decision does not speak to the medical necessity of this drug; it speaks to whether the Part D drug plan is responsible for payment under the Centers for Medicare and Medicaid Services (CMS) rules. 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 Nivestym 300 micrograms per milliliter solution for the prophylaxis or treatment of chemotherapy induced febrile neutropenia in an enrollee with a solid or non-myeloid cancer. 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. The documentation satisfies the plans coverage criteria. The prescriber clarified their answers to the plan's prior authorization criteria on 10/10/2022. The prescriber states the following:  The requested product will not be used within 24 hours prior to or following chemotherapy.The requested drug will not be used for any of the following indications: A) mobilization of peripheral blood progenitor cells (PBPCs), B) treatment of neutropenia in patients with myelodysplastic syndrome (MDS), C) following chemotherapy for acute myeloid leukemia (AML), D) neutropenia in aplastic anemia, E) human immunodeficiency virus (HIV)-related neutropenia, F) severe chronic neutropenia (congenital, cyclic, or idiopathic), G) agranulocytosis, H) neutropenia related to renal transplantation. The requested product is being prescribed for the prophylaxis or treatment of chemotherapy-induced febrile neutropenia. The request is for a patient with multiple myeloma.  The patient received, is currently receiving, or will be receiving treatment with myelosuppressive anti-cancer therapy.  A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Zolpidem Tartrate 10 milligram tablet to treat insomnia. 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. The documentation satisfies the plans coverage criteria. The provider has provided answers to the coverage criteria questions. Therefore, the patient has met the coverage criteria.  A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Corlanor 5 milligram tablet to treat heart failure due to dilated cardiomyopathy. 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.The use of the requested drug to treat the provided diagnosis is a medically accepted indication. Medical records support a resting heart rate of 90 beats per minute; chronic heart failure with an ejection fraction of 20 to 25 percent; a hospitalization for heart failure within one week of September 25, 20022; treatment by a cardiologist; use of maximally tolerated Toprol XR; and is unable to tolerate sufficient quantities of GDMT [Guideline-directed medical therapy (GDMT) for heart failure (HF) with reduced ejection fraction (HFrEF) now includes 4 medication classes which include sodium-glucose cotransporter-2 inhibitors (SGLT2i)]. The Medicare approved compendia contain a citation to support the use of the drug for the enrollees noted diagnosis. Therefore, the requested drug(s) is eligible for coverage under Medicare Part D.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 Vascepa 1 gram capsules to treat pure hypercholesterolemia. 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.Vascepa 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 Zopidem Tartrate 10 milligram tablet to treat insomnia. 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.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria.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 Breztri Aerosphere 160 microgram/9 microgram/4.8 microgram per actuation hydrofluoroalkane (HFA) aerosol to treat chronic obstructive bronchitis. 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. The requested drug is not on the plans formulary. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the documentation does not support why the formulary alternatives, required by the plan would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm. 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 Procrit 40,000 units per milliliter solution to treat iron deficiency anemia in an enrollee with overlap syndrome consisting of rheumatoid arthritis, systemic sclerosis, Sjogren's syndrome and systemic lupus, receiving Cellcept. 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. The use of the requested drug to treat the provided diagnosis 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 diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D. 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 Xifaxan 550 milligram tablet to treat small intestinal bacterial overgrowth (SIBO). 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 documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.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 Admelog 100 units per milliliter injection solution given daily via an insulin pump to treat type 2 diabetes mellitus. 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 records indicate the drug will be used in an insulin pump that is paid for by Medicare and will be used in the enrollees home. This drug is not eligible for coverage under Part D drug benefits. However, this drug may be covered under Medicare Part B benefits. We determined that the plan is not required to cover Admelog 100 units per milliliter injection solution.