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

You asked the Plan to cover Tymlos 3120 mcg/1.56 mL. The Plan did not grant this request. We receivedthis case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Tymlos 3120 mcg/1.56 mL. Tymlos is requested for ongoing treatment of post-menopausalosteoporosis in this enrollee without a history of a fracture, but who the prescriber has indicated is at highrisk for a fracture with a FRAX (Fracture Risk Assessment Tool) score of 50% for a major fracture and23% for a hip fracture. The prescriber initially indicated that the bone mineral density score was -2.2;however, clarified that the score was actually -2.6. Additionally, the prescriber has indicated that theenrollee has tried and failed and/or had adverse effects to Actonel and Alendronate. It is unclear if theenrollee satisfies the Plan's coverage criteria as discrepant information has been provided regarding thebone density T-score. However, based on the noted FRAX scores, the enrollee clinically has osteoporosisand requires ongoing treatment. The prescriber has indicated why all alternatives required by the Planwould likely not be as effective as the requested drug for the enrollee, and/or would likely cause adversereaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is medicallynecessary. 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. APlan must grant an exception to prior approval rules if it determines that the requested drug is medicallynecessary, consistent with the prescriber's statement. Based on the available documentation, our PhysicianReviewer's opinion is that an exception to prior approval criteria is met. Therefore, our decision is the Planis required to cover Tymlos 3120 mcg/1.56 mL.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Hydrocortisone 10 mg. The Plan did not grant this request. We received thiscase to conduct an independent review.In this case, the Plan denied Hydrocortisone on the basis that it is eligible for Medicare Part B. The caserecord indicates that Hydrocortisone is needed for a kidney transplant performed July 13, 2004. Thediagnosis given ongoing treatment of secondary adrenal insufficiency is not in the Medicare B rules andHydrocortisone is not eligible for coverage under Medicare Part B. We therefore asked our PhysicianReviewer to determine whether coverage criteria are met under Part D.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Hydrocortisone 10 mg. Hydrocortisone 10mg, #4 daily, #2 in the morning, #1 at noon and #1 at 6 pm, isrequested for ongoing treatment of secondary adrenal insufficiency. Details of the noted diagnosis andrequested corticosteroid regimen are documented in the medical record. Although the enrollee had aMedicare covered transplant in 2004 and was treated with Prednisone following transplant, the use ofHydrocortisone with the dosing schedule and total daily dose noted is documented to be for treatment of theenrollee's condition of secondary adrenal insufficiency. As such, the requested drug is eligible for coverageunder Medicare Part D. There are no applicable utilization management criteria identified for coverage ofthe drug. Our Physician Reviewer's opinion is that Medicare Part D criteria for coverage of the requesteddrug have been met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior authorization, step therapy orquantity limits. Hydrocortisone is on the Plan's formulary and is not subject to any of these restrictions.Therefore, our decision is the Plan is required to cover Hydrocortisone.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Apriso ER. 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 Apriso ER. The drug is requested to treat K52.9 Noninfective gastroenteritis and colitis, unspecified, which is an off-label (non-FDA approved) use. You sent a letter dated February 17, 2020 clarifying the medical history. Medical records from date of service January 30, 2020 were provided which substantiate this diagnosis. 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 Apriso ER 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 Apriso ER. 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 Nucala. 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 Nucala. Nucala is requested for ongoing treatment of eosinophilic asthma. It is noted that the enrollee was started on Nucala in January 2019. The plan denied coverage of Nucala because there was insufficient recent documentation indicating that the enrollee's condition has improved with the use of Nucala. The prescriber submitted medical records to the plan on two occasions; both were from the same patient encounter on January 28, 2019 when the enrollee was started on Nucala. The prescriber sent the same progress note with the request for reconsideration. The required documentation from a recent visit documenting the benefit of Nucala was not provided. The enrollee does not satisfy the Plan's coverage criteria. The prescriber has not sufficiently addressed the Plan's coverage criteria and/or has 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. .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 Nucala.
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 provide a tiering exception for Eliquis, 5 mg tablet. 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 a tiering exception for Eliquis, 5 mg tablet.The drug is requested to treat the enrollee's condition. The drug is a brand drug on tier 3 of the Plan's formulary. There are no available lower tier drugs on the Plan's formulary to treat the enrollee's condition. Therefore, the drug is not eligible for a tiering exception. Our Physician Reviewer's opinion is that tiering exception criteria are not met.Medicare rules permit a Plan to grant an exception to its tiering structure so long as there is a drug of the same type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) in a lower cost-sharing tier approved for treating the same condition that the higher cost-sharing tiered drug is being used to treat. Our Physician Reviewer's opinion is that tiering exception criteria are not met because there are no lower cost-sharing tiered drugs of the same type for treating the enrollee's condition. Therefore, our decision is the Plan is not required to provide a tiering exception for Eliquis, 5 mg tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Neupro, 8 mg/24 HR 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 a tiering exception for Neupro 8 mg/24 HR patch.Neupro 8 mg/24 HR patch is requested to treat the enrollee's condition. The requested drug is a brand drug on tier 4 of the Plan's formulary. There are no available lower tier brand drugs on the Plan's formulary to treat the enrollee's condition. Therefore, the drug is not eligible for a tiering exception. Our Physician Reviewer's opinion is that tiering exception criteria are not met.Medicare rules permit a Plan to grant an exception to its tiering structure so long as there is a drug of the same type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) in a lower cost-sharing tier approved for treating the same condition that the higher cost-sharing tiered drug is being used to treat. Our Physician Reviewer's opinion is that tiering exception criteria are not met because there are no lower cost-sharing tiered drugs of the same type for treating the enrollee's condition. Therefore, our decision is the Plan is not required to provide a tiering exception for Neupro, 8 mg/24 HR patch.
Appeal type: Prescription Drug
Decision: Partially Favorable

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 and provide reimbursement for Hepatitis A vaccine and Hepatitis B vaccine received on September 18, 2019, from your physician's office. The Plan did not grant this request. We received this case to conduct an independent review.You asked the Plan to cover and provide reimbursement for Hepatitis A vaccine and Hepatitis B vaccine.Regarding coverage and reimbursement for Hepatitis A vaccine: The Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. The record indicates that you received Hepatitis A vaccine, a Medicare-covered vaccine, from your physician's office on September 18, 2019. The case record includes proof of payment showing that you have paid the bill for Hepatitis A vaccine and its administration in full. The Plan's out-of-network coverage rules were followed. Therefore, our decision is the Plan is required to cover and provide any applicable reimbursement for Hepatitis A vaccine received September 18, 2019, from your physician's office.Regarding coverage and reimbursement for Hepatitis B vaccine: Medicare law specifically excludes coverage for any drug for which payment would be available under Parts A or B of Medicare for that individual. Medicare law states that Medicare Part B pays for the Hepatitis B vaccine for the prevention of illness for those individuals who are at high or intermediate risk of contracting Hepatitis B.In this case, we reached out to your physician's office to verify whether you are or were at high or intermediate risk of contracting Hepatitis B. However, we were unable to obtain this information within the timeframe required for review of this case. The documentation in the case record is insufficient to establish that you are NOT at high or intermediate risk of contracting Hepatitis B. Thus, the record does not support that Hepatitis B vaccine is a Part D drug in this case. Therefore, our decision is the Part D Plan is not required to cover or provide reimbursement for Hepatitis B vaccine.This decision does not concern the medical necessity or appropriateness of Hepatitis B vaccine. It only establishes if payment can be made under the Medicare Part D benefit.Please contact the Plan for more information regarding coverage of Hepatitis B vaccine under the Part B benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Colestipol HCL. 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 Colestipol HCL. The drug is requested to treat diarrhea, 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. 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 Colestipol HCL 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 Colestipol HCL. 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.Please note: the request for a tiering exception (lower copayment) for Colestipol HCL was not reviewed. We cannot consider a tiering exception for a drug for which the Part D Plan is unable to provide coverage.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Megestrol Acetate 40 mg. 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 Megestrol Acetate 40 mg tablet. Megestrol Acetate is requested for treatment of the enrollee's condition which includes the diagnosis of C54.1 - Malignant neoplasm of endometrium which is supported in the documentation provided. Details of the enrollee's condition are well documented in the medical records and on the Plan's case file transmittal form. For coverage under the prescription drug benefit, Medicare requires that the drug prescribed be used for a medically accepted indication. The Plan concluded that ICD-10 C54.1 is not a medically accepted indication for the use of the requested drug; however the use of Megestrol Acetate is a 2A recommendation in NCCN National Comprehensive Cancer Network, for treatment of the stated condition. 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. The enrollee satisfies the Plan's coverage criteria. Our Physician Reviewer's opinion is that prior authorization criteria are met.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 citations in the Medicare approved compendia that support the use of Megestrol Acetate 40 mg for the diagnosed condition. As a result, Megestrol Acetate 40 mg is being prescribed for a medically accepted indication as defined by Medicare law. 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 Megestrol Acetate 40 mg.Please note that if the Plandoes not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The health plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will notify you in writing that the case is being reviewed again and the outcome of the reopening.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Clorazepate. 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 Clorazepate. The drug is requested to treat generalized anxiety disorder (GAD), psychophysiologic insomnia, and reaction to severe stress/post-traumatic stress disorder (PTSD), which are off-label (non-FDA approved) uses. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted conditions. 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 Clorazepate 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 Clorazepate. 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 provide a tiering exception for Ozempic. 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 a tiering exception for Ozempic 2 mg/1.5 ml pen. Ozempic 2 mg/1.5 ml pen is requested to treat your condition. The requested drug is a brand drug on Tier 3 of the Plan's formulary. There are no available lower tier brand drugs on the Plan's formulary to treat your condition. Therefore, the drug is not eligible for a tiering exception. Our Physician Reviewer's opinion is that tiering exception criteria are not met.Medicare rules permit a Plan to grant an exception to its tiering structure so long as there is a drug of the same type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) in a lower cost-sharing tier approved for treating the same condition that the higher cost-sharing tiered drug is being used to treat. Our Physician Reviewer's opinion is that tiering exception criteria are not met because there are no lower cost-sharing tiered drugs of the same type for treating the enrollee's condition. Therefore, our decision is the Plan is not required to provide a tiering exception for Ozempic.
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 provide a tiering exception for Mexiletine HCL. The Plan did not grant this request. We received this case to conduct an independent review.The Plan provided documentation that coverage (as a formulary exception) was approved by the Plan. Therefore, we are dismissing the request for coverage for Mexiletine HCL. You should contact the Plan for more information regarding how and when coverage for Mexiletine HCL will be provided.Medicare law and Plan rules do not allow tiering exceptions for non-formulary drugs being covered through a formulary exception. The documentation in the record shows that Mexiletine HCL is currently being covered for the enrollee through a formulary exception. Therefore, our decision is the Plan is not required to provide a tiering exception for Mexiletine HCL.