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

The enrollee requested Cyanocobalamin 1000 microgram/milliliter prescribed for unknown diagnosis. 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. According to Medicare rules, drugs that fall into the category of vitamins and minerals are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover the Cyanocobalamin. There is no evidence the plan offers supplemental benefits for the Cyanocobalamin. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Iclusig 30 milligram tablets prescribed for FLT3 positive, BCR-ABL positive acute myeloblastic leukemia. The Part D plan denied the request. We performed 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 submitted documentation indicates the prescriber ordered Iclusig for FLT3 positive, BCR-ABL positive acute myeloblastic leukemia. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. There are no Medicare approved journal articles to support the use of the drug for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Euflexxa 20 milligram/2 milliliter Soln Pref Syringe prescribed for unknown use. 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. We determined that the plan is not required to cover the Euflexxa. Euflexxa is a drug that is injected into the knee and is considered a device by the Food and Drug Administration. Therefore, the device is excluded from coverage under Medicare Part D. However, the device may be covered under your Part B benefit because it is supplied and administered by a physician in the physician's office. The decision does not address medical necessity of the device. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Metanx 3/90.314/2/35 milligram capsule for unknown diagnosis.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.According to Medicare rules, drugs that are considered a medical food are excluded from coverage under Part D. We reviewed Food and Drug Administration (FDA)-approved sources for the drugs classification or determined from other available resources that the drug is considered a medical food. The plan indicates that supplemental coverage is not provided under the Part D benefit for this drug. Therefore, we determined that the Part D plan is not required to cover the Metanx. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Blincyto 35 microgram intravenous solution prescribed for the enrollees condition. The Part D plan denied the request. We performed 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 drug at issue is for use in an external infusion pump in the enrollees home. This is eligible for coverage under Part B. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for Mycophenolate Mofetil 500 milligram tablet was prescribed for interstitial lung disease, unspecified. The Part D plan denied your 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 documentation shows Mycophenolate Mofetil 500 milligram was prescribed to treat lung disease associated with rheumatoid arthritis. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Megestrol Acetate 20-milligram tablet to treat Parkinsons disease and cachexia due to dementia. The Part D plan denied your 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 documentation shows your doctor prescribed Megestrol Acetate to treat your Parkinsons disease and cachexia due to dementia. However, the Medicare approved compendia do not support the use of this drug for your conditions. 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 Lantus SoloStar 100 unit/milliliter prescribed as directed for type 2 diabetes mellitus without complications. The Part D plan denied your 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. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. . However, we did not receive the documentation.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 medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Lantus SoloStar.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Calcitriol 0.5 microgram capsule prescribed for hyperparathyroidism. The Part D plan denied the request. We performed 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 enrollee has an end-stage renal disease facility enrollment. This is eligible for coverage under Part B. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Colesevelam Hydrochloride 625-milligram tablet to treat diarrhea in high output ostomy and hyperlipidemia. The Part D plan denied the request. The requested drug is not on the plans formulary. We performed 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.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs to treat hyperlipidemia must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you.  The prescriber appeal letter dated 8/16/2021 states that the requested drug is being used to treat high out flow from the enrollee's ostomy.   The use of the requested drug to treat high ostomy output 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.  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 Rocklatan eye drops prescribed for low-tension glaucoma, bilateral, severe stage. 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.Rocklatan is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no brand 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 plan is not required to cover the requested drug at a lower cost tier level. The drug will continue to be covered at the Tier 3 copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Basaglar 100 unit/milliliter kwikpen. The Part D plan denied your request for a tiering exception.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. This drug is provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300-milligrams/2-milliliters subcutaneous pen to treat photo-triggered dermatitis. The Part D plan denied the request. We performed 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 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 condition. Therefore, the requested drug 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 Lynparza 150 milligram tablet prescribed for metastatic castrate resistant prostate cancer, CHEK2 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 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. Per compendia, Lynparza is a category 1 recommendation from the National Comprehensive Cancer Network for single-agent for castration-resistant distant metastatic disease for patients who have been treated with androgen receptor-directed therapy and have a pathogenic mutation in a homologous recombination repair gene which include BRCA1, BRCA2, ATM, BARD1, BRIP1, CDK12, CHEK1, CHEK2, FANCL, PALB2, RAD51B, RAD51C, RAD51D or RAD54L, if Olaparib not previously received and if enrollee received prior novel hormone therapy. The prescriber indicates that the enrollee received prior novel hormone therapy. However, no medical records were submitted to support a treatment plan with any other drugs to be used, prior treatments, and if the prescriber will be using single agent Lynparza (with Lupron) without chemotherapy. We requested additional information from the prescriber but did not get a response. It was unable to be determined if the requested drug is to be used per recommendations and guidelines of the National Comprehensive Cancer Network and Medicare approved compendia. A physician reviewed your appeal and determined that the plan is not required to cover Lynparza.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Nerlynx 40 milligram tablet prescribed for bilateral breast cancer, HER2 positive. 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 medical records show that Nerlynx was prescribed for an enrollee with bilateral breast cancer, HER2 positive. The enrollee was initially diagnosed in 1990 with right breast cancer and underwent surgery, chemotherapy, and radiation. In 2019, the enrollee underwent chemotherapy with TCH, a bilateral mastectomy, and treatment with adjuvant Kadcyla for recurrence. Surgery showed stage 3 disease, HER2 positive, HR positive disease and residual disease making patient a high risk for recurrence. There is concern about patients cardiac function as they had multiple cardiotoxic therapies and ejection fraction is 30%. Prescriber requesting Nerlynx which was previously denied as the enrollee is also on Anastrazole. Per Medicare approved compendia and the Food and Drug Administration, Nerlynx is indicated for extended adjuvant treatment after Trastuzumab containing therapy in HR positive, HER2 positive disease at high risk for recurrence. The enrollee has received Trastuzumab containing therapy as above; in addition she is at high risk of recurrence due to stage 3 and residual disease. The enrollee will be taking this drug with Anastrazole. Based on the ExteNET trial that approved Nerlynx, 57% of patients were hormone positive and concurrent adjuvant endocrine therapy for HR positive disease was recommended in the trial and the trial is what compendia is based upon. The enrollee has a Food and Drug Administration indication of extended adjuvant, early stage HER2 positive breast cancer following adjuvant Trastuzumab based therapy. Genetic testing has been completed, if required, for therapy with the requested agent and results indicate the requested agent is appropriate (enrollee has documented HER2 positive disease) and enrollee does not have any Food and Drug Administration labeled contraindications to the requested agent and enrollee has tried Kadcyla, TCH therapy, and has a contraindication to Perjeta due to congestive heart failure. The prior authorization requirements have been met. A physician reviewed your appeal and determined that the plan is required to cover Nerlynx.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tymlos 80-microgram/dose Pen Injector, 46.8-milliliters per 30-days to treat osteoporosis. The Part D plan denied the request. We performed 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 to of Tymlos 80-microgram/dose Pen Injector to 1.56-milliliters per 30-days. The prescriber indicates the quantity billed to the plan was in error and is requesting the quantity to be changed. However, at reconsideration the Qualified Independent Contractor cannot change the quantity from the billed amount. As such, the claim will have to be rebilled to the plan with the correct dosage and quantity. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that quantity limit criteria are not met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Sirturo 100-milligram tablet to treat indeterminate leprosy. The Part D plan denied the request. We performed 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.At reconsideration a diagnosis of pulmonary mycobacterial infection was given. The documentation satisfies the plans coverage criteria. 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 Armodafinil 50 milligram tablets prescribed for excessive daytime sleepiness associated with treatment of Parkinsons disease. The Part D plan denied the request. We performed 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 submitted documentation indicates the prescriber ordered Armodafinil for excessive daytime sleepiness associated with treatment of Parkinsons disease. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Lidocaine-Prilocaine cream 2.5/2.5% prescribed for the treatment of encounter for adjustment and management of vascular access device/chemo therapy. 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.According to Medicare rules, drugs that are not approved by the Food and Drug Administration are excluded from coverage under Part D. Lidocaine-Prilocaine cream has not been approved by the Food and Drug Administration to be safe and effective. Therefore, we determined that the plan is not required to cover the Lidocaine-Prilocaine cream. If you purchased drugs/products that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug/product. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dronabinol 10-milligram capsule to treat gastroesophageal reflux disease and gastroparesis. The Part D plan denied the request. We performed 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 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 condition. Therefore, the requested drug 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 Azathioprine 50 milligram tablets prescribed for chronic inflammatory demyelinating polyneuritis. The Part D plan denied the request. We performed 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 submitted documentation indicates the prescriber ordered Azathioprine for chronic inflammatory demyelinating polyneuritis. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested compounded drug C-Interferon Alfa2B 1 M IU/ML prescribed daily for squamous cell carcinoma of the conjunctiva in the right eye. 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 levelThe record shows the C-Interferon alfa 2b is a compounded drug and each ingredient is reviewed individually. Medicare Part D does not cover drugs that do not meet the definition of a Part D drug. Therefore, we determined that the plan is not required to cover or reimburse for the ingredients Sterile Water for injection 20 milliliter and Droptainer 3 milliliter Sterile. The plan provided documentation showing the Medicare rules for the Intron A have been met effective July 16, 2019 through May 12, 2021. Medicare rules allow a Part D plan to manage its formulary by requiring prior authorization, step therapy or quantity limits. Prior authorization has been met for the Intron A for a 30 day supply. However, reimbursement is requested for a 50 day supply. Therefore, the plan is not required to provide reimbursement at this time.