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

At issue is Tukysa 150 milligram tablet prescribed for metastatic HER2 positive esophageal adenocarcinoma. 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 documentation shows Tukysa was prescribed for metastatic HER2 positive esophageal adenocarcinoma. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Tukysa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is the request for Otrexup 15 milligram/0.4 milliliter subcutaneous injection prescribed for dermatopolymyositis. 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 documentation shows the doctor prescribed Otrexup to treat the patients dermatopolymyositis. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Otrexup.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lumakras metastatic stage IV colon cancer positive for KRAS G12D and G12C mutations. 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 documentation shows Lumakras was prescribed to treat metastatic stage IV colon cancer, positive for KRAS G12D and G12C mutations. 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. 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 your appeal and determined that the plan is not required to cover Lumakras.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram tablet prescribed twice daily. The Part D plan denied the request for a tiering exception.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. Eliquis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Glatiramer acetate 40 milligram/milliliter syringe prescribed three times a week. The Part D plan denied the request for a tiering exception.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. This drug is included on Tier 5 of the plans formulary. This tier is identified as a specialty tier. The plan is not required to grant a tiering exception for drugs available on their specialty tier. Therefore, a tiering exception cannot be considered.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Meningococcal vaccine prescribed for vaccination. The Part D plan denied the enrollees 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 record shows the enrollee was administered the Meningococcal vaccine at their physicians office. Payment for vaccines including administration fee is required up front when provided at an out of network pharmacy or provider's office. You will be reimbursed the amount you paid less any deductible, copayment or coinsurance and less the amount the physician charges and the plans approved amount. The enrollee submitted documentation that shows National Drug Codes are provided for this drug. However, according to the Food and Drug Administration, the codes provided, are not valid. In addition, there is no request for reimbursement or receipt showing the enrollee paid the full amount of the vaccine and administration fee, as required by the plans Evidence of Coverage, regarding vaccine administration from a physician or provider's office. Therefore, we determined that the plan is not required to reimburse the enrollee for the vaccine and administration fee at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Obrexza 2.4% cloth. The Part D plan denied the appeal request for a tiering exception.The QIC 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.Obrexza 2.4% cloth 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 the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Minocycline Hydrochloride 100 milligram tablet prescribed daily for osteoarthritis. 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.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication was needed. We received the documentation and included it in our review.The documentation shows the doctor prescribed Minocycline Hydrochloride tablets to treat the enrollees osteoarthritis. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Minocycline Hydrochloride tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Macrilen 60 milligram/120 milliliter solution prescribed for growth hormone deficiency. 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 incident to a physician procedure. 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 Zolpidem Tartrate 12.5 milligram extended release tablets prescribed for 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 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.We requested additional documentation from the prescriber. Specifically, we requested medical records and a prescriber statement to support all formulary alternatives were tried and failed. We received the requested documentation and included in the review.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 the enrollee. A physician reviewed the appeal and determined that the plan is not required to cover Zolpidem Tartrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Octreotide Acetate 1000 microgram/milliliter prescribed for short bowel syndrome. 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 documentation shows Octreotide Acetate was prescribed to treat short bowel syndrome. However, the Medicare approved compendia do not support the use of this drug for the enrollee's condition. A physician reviewed your appeal and determined that the plan is not required to cover Octreotide Acetate.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Aimovig 70 milligram/milliliter injector prescribed for migraine headaches. 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 records submitted at the reconsideration level. The documentation shows the physician prescribed Aimovig to treat the patients migraine headaches. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation supports the patient satisfies the plan's coverage criteria. The prescriber submitted a statement to support the patient was prescribed Aimovig to treat their migraine headaches. The prescriber states the patient was diagnosed with migraines and was using Emgality until insurance denied for formulary issues. Prescriber states the patient has also tried Keppra for over 4 weeks. A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Horizant extended release 600 milligram tablets prescribed to assist with extreme pain that is escalating. 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 the case file and all documentation submitted. This includes any information submitted at the reconsideration level. The documentation indicates that Horizant extended release 600 milligram tablet is prescribed to assist with extreme pain that is escalating. 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. We requested additional information from the prescriber but did not receive the information. Therefore, the requested drug is not eligible for coverage under Medicare Part D.  A physician reviewed your appeal and determined that the plan is not required to cover Horizant extended release tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acuvail 0.45% ophthalmic solution. The initial determination and redetermination lists diagnoses of keratoconjunctivitis sicca, not specified as Sjogren's , and bilateral and acute follicular conjunctivitis. 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. At reconsideration a diagnosis of episcleritis was given.  The diagnosis provided in the appeal was acute follicular conjunctivitis and keratoconjunctivitis sicca.  Medical records were requested and no medical records were provided.  The Medicare approved compendia do not support the use of Acuvail for the enrollees conditions. A physician reviewed your appeal and determined that the plan is not required to cover Acuvail.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Restasis 0.05% eye emulsion. The Part D plan denied the appeal request for a tiering exception.The QIC 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.Restasis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Dayvigo 10 milligram tablets prescribed for insomnia. 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 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. Dayvigo is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyzulta 0.024% eye drops prescribed daily. The Part D plan denied the request for a tiering exception.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. 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 the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycontin 30-milligram tablet Extended Release 12-Hour Abuse-Deterrent to treat chronic lumbar degenerative joint and disc disease with chronic mechanical low back pain and severe right knee pain due to degenerative joint disease. 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. 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 drug (Xtampza) on the plans formulary would not work for you. 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 Vraylar 3 milligram capsules prescribed to treat bipolar II disorder. The Part D plan denied the appeal request.The QIC 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 documentation shows the doctor prescribed Vraylar 3 milligram capsules to treat bipolar II disorder. However, the Medicare approved compendia do not support the use of this drug for your condition.A physician reviewed the appeal and determined that the plan is not required to cover Vraylar 3 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nucynta 50 milligram prescribed once daily for chronic pain and cervicalgia. 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.  Note that medical records were requested and were not provided.The documentation shows Nucynta was prescribed to treat chronic pain and cervicalgia. However, the Medicare approved compendia do not support the use of this drug for the enrollee's condition. A physician reviewed your appeal and determined that the plan is not required to cover Nucynta.
Appeal type: Prescription Drug
Decision: Favorable

You requested Humira 40 milligram/0.4 milliliter injection prescribed for panuveitis. 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 Humira was prescribed to panuveitis. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for your condition: Humira is indicated for the treatment of noninfectious intermediate, posterior and panuveitis.A physician reviewed your appeal and determined that the plan is required cover Humira.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Lidocaine 5% ointment. 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 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 documentation indicates that Lidocaine 5% ointment has been prescribed for a stage 4 pressure ulcer in a paraplegic enrollee. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trelegy Aer Ellipta 100-62.5-25 microgram/inhalation prescribed as directed. 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. Trelegy Aer Ellipta is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is 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 Humira CF 40 milligram/0.4 milliliter subcutaneous solution prescribed for undifferentiated inflammatory arthritis. 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 Humira CF for undifferentiated inflammatory arthritis. The prescriber submitted a statement stating the enrollee has a diagnosis of psoriatic arthritis; however, the medical records submitted do not support a change in diagnosis. The Medicare approved compendia do not support the use of the biologic at issue for the enrollees condition. As the biologic 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 biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armodafinil 150 milligram tablets prescribed for multiple sclerosis related fatigue. 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 multiple sclerosis related fatigue. 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

At issue is a request for coverage of Uribel 118-40.8-36-10-0.12 milligram capsules prescribed for the treatment of chronic interstitial cystitis. 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.Uribel has not has not been approved by the Food and Drug Administration for safety and effectiveness. Drugs not approved by the Food and Drug Administration are excluded from Part D coverage. We have determined that the Medicare Part D plan is not required to cover the requested drug. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.