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

At issue is coverage for Mycophenolic tablet 360 milligrams DR (delayed release) to treat interstitial lung disease/hypersensitivity pneumonitis. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Eletriptan Hydrobromide 40 milligram tablet, 90 tablet per 30 days to treat migraine headache. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The plans quantity limit for the requested drug is 12 tablets per 30 days. The prescriber has not provided patient-specific clinical rationale as to why the amount allowed by the plan would be ineffective in treating the diagnosis and/or would be contraindicated. Furthermore, the submitted documentation does not support the medical necessity for an exception to the plans quantity limit for the drug. A physician reviewed the appeal and determined that the requested drug at the requested amount is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Neulasta 6 milligram/0.6milliliter solution prefilled syringe to treat neutropenia prophylaxis with malignant neoplasm of stomach using chemotherapy. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The requested drug is not on the plans formulary. To grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed or must be deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale as to why the alternative drugs on the plans formulary to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Additionally, the submitted documentation does not support that the enrollee has tried and failed all of the formulary alternative drugs. Therefore, the formulary exception requirements have not been met.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Fulphila 6 milligram per 0.6 milliliter solution prefilled syringe to treat prophylaxis for neutropenia in enrollee with lung cancer receiving chemotherapy regimen. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The requested drug is not on the plans formulary. To grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed or must be deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale as to why the alternative drugs on the plans formulary to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Additionally, the submitted documentation does not support that the enrollee has tried and failed all of the formulary alternative drugs. Therefore, the formulary exception requirements have not been met.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Aimovig 140 milligram per milliliter autoinjector to treat migraine, unspecified, not intractable, without status migrainosus. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. Furthermore, the documentation does not support the medical necessity for an exception to the plans prior authorization requirements.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliquis 5 milligram tablet prophylaxis against stroke and embolism in a patient with atrial fibrillation. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Eliquis is a brand on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

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

At issue is coverage for Potassium Citrate/Citric Acid 1100/334 milligram/5 milliliter solution. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Potassium Citrate/Citric Acid solution is a prescription vitamin / mineral. Prescription vitamin and mineral products are excluded from coverage under Medicare Part D. This is regardless of whether the vitamin or mineral product is being prescribed to correct a deficiency or to treat a disease process. Therefore, the requested drug is excluded from Medicare Part D coverage. This decision does not address the medical necessity 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 coverage for Temozolomide 180 milligram capsule to treat malignant neoplasm of brain. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Coverage is available under Medicare Part B for drugs taken orally during chemotherapy if they have the same active ingredients (or are pro-drugs) as chemotherapy drugs that would be covered if they were not self-administered. (i.e., intravenous drugs). Therefore, coverage of this drug would be available under Medicare Part B. Medicare rules state that any drug available for coverage under Medicare Part B cannot be covered under Part D. This decision does address the medical necessity of the requested drug. It only establishes that payment cannot be made under the Part D benefit. Please submit the request for coverage through Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Ozempic 2 milligram per dose (8 milligram per 3 milliliter) subcutaneous solution to treat prediabetes. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Krazati 200 milligram oral tablet to treat malignant neoplasm of rectum. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. The submitted documentation does not include any clinically relevant, peer-reviewed medical literature from a Medicare approved journal to support this appeal. Therefore, the available documentation supports that 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 Catapres-TTS-3 patch. 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. According to Medicare rules, Part D drug plans do not cover drugs produced by a manufacturer who does not participate in the Medicare Gap Discount Program. The Center for Medicare and Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. According to the list, the manufacturer did not sign the agreement and does not participate in the Medicare Gap Discount Program. Therefore, we determined that the plan is not required to cover the Timolol Maleate. 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 coverage for Jardiance 25 milligram tablet to treat type 2 diabetes mellitus without complications. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Jardiance is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Praluent 75 milligram/milliliter solution auto injector to treat atherosclerotic heart disease of native coronary artery and hyperlipidemia. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The requested drug is not on the plans formulary. To grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed or must be deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale as to why the alternative drugs on the plans formulary to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Additionally, the submitted documentation does not support that the enrollee has tried and failed all of the formulary alternative drugs. Therefore, the formulary exception requirements have not been met.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Methenamine/Sodium Phosphate/Methylene Blue/Hyoscyamine tablet to treat dysuria. The Part D plan denied the request for coverage and then auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Methenamine/Sodium Phosphate/Methylene Blue/Hyoscyamine has not been found by the Food and Drug Administration (FDA) to be safe and effective, and the drug product labeling has not been approved by the FDA. Drugs that are not FDA-approved do not meet the definition of a Part D drug and are excluded from Part D coverage. Therefore, the requested drug is excluded from Medicare Part D coverage.This decision does not address the medical necessity of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Qulipta 10 milligram tablet prescribed 20 milligram twice daily tablet to treat chronic migraine without aura, intractable, without status migrainosus. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. Furthermore, the documentation does not support the medical necessity for an exception to the plans prior authorization requirements.The plans quantity limit for the requested drug is 30 tablets per 30 days. The prescriber has not provided patient-specific clinical rationale as to why the amount allowed by the plan would be ineffective in treating the diagnosis and/or would be contraindicated. Furthermore, the submitted documentation does not support the medical necessity for an exception to the plans quantity limit for the drug. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Procrit 40000 unit/milliliter vial to treat anemia associated with chronic kidney disease. The Part D plan denied the request for coverage and then auto forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. Furthermore, the documentation does not support the medical necessity for an exception to the plans prior authorization requirements.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Ozempic 1 milligram per dose (4 milligram per 3 milliliter, 9 milliliter per 28 days, to treat type 2 diabetes mellitus. The Part D plan denied the request for coverage and then auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The plans quantity limit for the requested drug is 4 milliliter per 28 days. The prescriber has not provided patient-specific clinical rationale as to why the amount allowed by the plan would be ineffective in treating the diagnosis and/or would be contraindicated. Furthermore, the submitted documentation does not support the medical necessity for an exception to the plans quantity limit for the drug. A physician reviewed the appeal and determined that the requested drug at the requested amount is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Remodulin 2.5 milligram per milliliter vial to treat idiopathic pulmonary arterial hypertension. The Part D plan auto-forwarded the case to us for review. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. The submitted documentation indicates that the requested drug is being administered via a home infusion pump. Medicare classifies home infusion pumps as durable medical equipment. Medicare rules state that Medicare Part B pays for the rental and purchase of durable medical equipment. Additionally, payment will be made under Medicare Part B for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals, which must be put directly into the equipment. Any drug available for coverage under Medicare Part B cannot be covered under Part D, per Medicare rules. Therefore, the requested drug is not eligible for Medicare Part D coverage.This decision does not address the medical necessity of the item. It only establishes that payment cannot be made under the Medicare Part D benefit. Please submit the request for coverage through Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Mounjaro 2.5 milliliter pen to treat obesity. The Part D plan denied the request for coverage and then auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Drugs prescribed to treat obesity and/or to promote weight loss are excluded from the Part D coverage. Therefore, the requested drug is excluded from Medicare Part D coverage. This decision does not address the medical necessity 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 coverage for Chlordiazepoxide 25 milligram capsule to treat seizure disorder. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication. As this drug is ineligible for Part D coverage, it is ineligible for consideration for a formulary exception.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 Ozempic 1 milligram per dose (4 milligram per milliliter) ,12 per 84 days solution pen injector, to treat type 2 diabetes mellitus. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The plans quantity limit for the requested drug is 4 milliliter per 28 days. The prescriber has not provided patient-specific clinical rationale as to why the amount allowed by the plan would be ineffective in treating the diagnosis and/or would be contraindicated. Furthermore, the submitted documentation does not support the medical necessity for an exception to the plans quantity limit for the drug. A physician reviewed the appeal and determined that the requested drug at the requested amount is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Armodafinil 150 milligram tablets to treat multiple sclerosis related daytime fatigue. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Mounjaro 2.5 milligram per 0.5 milliliter pen to treat prediabetes. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Jardiance 25 milligram oral tablet. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Jardiance is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.