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

At issue is Lidocaine 5-percent patch to treat radiculopathy, lumbar region and unilateral primary osteoarthritis of the right hip, and fibromyalgia. The case was auto-forwarded by the plan. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.We requested additional information from your prescriber. We did not receive a response. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The diagnosis submitted does not meet the prior authorization requirements. The enrollee has not satisfied the plan's coverage criteria. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine 10 milligram tablet. The case was auto-forwarded by the Part D plan.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.We requested additional information from the prescriber. Specifically, we requested a medically accepted indication, asked if the benefits outweigh the risks of taking this high risk medication, medical records, and a prescriber statement to support that the enrollee has satisfied the plans prior authorization coverage criteria. However, we did not receive the requested information.No documentation was provided by the prescribe. We requested information from the prescriber but no information was received. We are not able to determine whether the requested drug was prescribed for a medically accepted indication. Therefore, the 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: Favorable

At issue is Zenpep 40, 000 unit capsule to treat pancreatic insufficiency. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The plan has prior authorization coverage criteria that must be met prior to approval. The criteria indicates the enrollee must have a Food and Drug Administration approved indication. The Medicare approved compendia contain a citation to support the use of the drug for the enrollees noted diagnosis. Therefore, an exception to the plans coverage criteria is medically necessary.Zenpep is a biologic on Tier 3 of the plans formulary. The prescriber has stated that all lower tiered biologics to treat the diagnosis have been tried and failed or provided reasons why they would likely not be as effective as the requested biologic. Therefore, this biologic is eligible for an exception. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage and a tiering exception.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Kineret 100 milligram per 0.67 milliliter solution prefilled syringe to treat seropositive rheumatoid arthritis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The drug at issue is not on the plans formulary. The prescriber provided patient specific clinical rationale supported by documentation, indicating why the formulary alternatives, required by the plan, would likely not be as effective as the requested drug for this diagnosis, and/or would likely cause adverse reaction(s) or other harm. Specifically, the prescriber statement and medical records indicate the enrollee is being treated for acute myeloid leukemia and the formulary alternative would likely cause adverse reaction or othet harmr . Therefore, an exception to the plans formulary coverage criteria is medically necessary.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Kesimpta 20 milligrams per 0.4 milliliter solution auto-injector to treat multiple sclerosis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The requested drug is not on the plans formulary. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the documentation does not support why the formulary alternatives, required by the plan would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sodium Benzoate powder prescribed for non-ketotic hyperglycinemia. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Drugs that fall into the category of bulk powders do not meet the definition of a Part D drug. The requested drug is considered a bulk powder and is excluded from coverage under Part D. 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 Trulance 3 milligram tablet to treat ppioid induced constipation. The Part D plan denied the request.  We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is ZTlido 1.8 percent patch to treat cervical discitis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliquis 5 milligram tablet. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. Eliquis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this drug is not eligible for a tiering exception. A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ondansetron Hydrochloride 8 milligram tablet to treat nausea. The Part D plan denied the request.  We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide 3-milligram capsule to treat protein losing enteropathy. We received the case to perform an independent and de novo review. To make our decision, we reviewed any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5 percent patch to treat low back pain. The Part D plan denied the request.  We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem tartrate 12.5 milligram extended release tablet to treat the enrollees condition. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The requested drug is not on the plans formulary. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the documentation does not support why the formulary alternatives, required by the plan would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm. As such, the plan is not required to reimburse the enrollee for the cost of 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 Movantik 25 milligram tablet to treat opioid-induced constipation and adverse effect of other opioids. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vesicare 5 milligram tablet to treat urge incontinence. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. The requested drug is not on the plans formulary. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the documentation does not support why the formulary alternatives, required by the plan would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armodafinil 50 milligram tablet to treat fatigue secondary to multiple sclerosis. The Part D plan denied the request.  We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diovan-Hydrochlorothiazide 160-125 milligram tablets to treat hypertension. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The requested drug is not on the plans formulary. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the documentation does not support why the formulary alternatives, required by the plan would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5 percent patches to treat phantom limb pain, disorder of rotor cuff, right shoulder pain. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.At reconsideration, a diagnosis of left knee tricompartmental osteoarthritis was given; however, the prescribing physician did not give this diagnosis. We requested additional information from the both physicians. Specifically, we requested the enrollees pain etiology and history, medical records and a prescriber statement to support the enrollee has satisfied the plans prior authorization coverage criteria. However, we did not receive the requested information.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is coverage for Oxycodone Hydrochloride 5 milligram tablets for 50 tablets per 30 days. 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 documentation submitted. During the review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to provide the diagnosis being treated and to address the plans coverage requirements for the drug. We received additional documentation and included it in the review.The newly submitted prescriber statement and medical records support that the plans requirements for the requested drug have been satisfied. The documentation indicates the requested drug has been prescribed to treat acute pain severe enough to require an opioid analgesic due to post-surgery following a spontaneous rupture of the flexor tendon, osteoarthritis, and impingement syndrome of the right shoulder. The use of the requested drug to treat acute pain severe enough to require an opioid analgesic is a medically accepted indication for the drug outlined in the Medicare approved compendia. Additionally, the prescriber has indicated that the enrollee can safely take the requested dose based on their history of opioid use and that the enrollee has been evaluated and will be monitored for the development of opioid use disorder. While the prescriber has indicated that the enrollee is opioid naive, the submitted medical records support the medical necessity for more than a 7-day supply of the requested drug. Furthermore, the documentation confirms that the enrollee is not taking an opioid and a benzodiazepine concurrently. Finally, the amount requested does not exceed the plans quantity limit for the drug. As such, the plans requirements have been satisfied and coverage for the drug is supported.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Rhopressa 0.02 percent solution to treat primary open angle 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 reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Rhopressa is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this drug is not eligible for a tiering exception.A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligram per milliliter pen injector to treat hypercholesterolemia. The Part D plan denied your request.  We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyproheptadine Hydrochloride 4 milligram tablet to treat anorexia. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed for the treatment of weight loss are excluded from coverage. Therefore, this drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine 10 micrograms per hour patch weekly to treat spondylosis without myelopathy or radiculopathy, cervical region. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The requested drug is not on the plans formulary. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the documentation does not support why the formulary alternatives, required by the plan would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aduhelm Solution (intravenous infusion) 300 milligrams per 3 milliliter. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. In accordance with the National Coverage Analysis (NCA), Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimers Disease CAG-00460N https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&ncaid=305, Aduhelm is indicated for the treatment of Alzheimers disease and should be initiated in patients with mild cognitive impairment (MCI) or mild dementia stage of disease (the population in which treatment was initiated in clinical trials). There are no safety or effectiveness data on initiating treatment at earlier or later stages of the disease than were studied. Alzheimers disease with MCI or mild dementia stage of disease is approved under accelerated approval based on reduction in amyloid beta plaques observed in patients treated with Aduhelm. Continued approval for this indication may be contingent upon verification of clinical benefit in confirmatory trial(s). The submitted clinical evidence includes spinal tap results showing the the Beta Amyloid 42/40 ratio result was 0.040. This report indicates a result of less that 0.058 shows there is a higher likelihood of the patient having a diagnosis of Alzheimers disease. However, the submitted evidence does not contain a clinical progress note or any other clinical documentation to support the enrollees prescribed diagnosis is in fact Alzheimer's disease with MCI or stroke. The enrollee's prior two magnetic resonance imaging (MRI) reports dated January 26, 2021, and May 8, 2019, did not show a stroke whereas the enrollee's most recent MRI dated February 3, 2022, shows shows a lacunar infarct and evidence of small vessel ischemic disease, indicating signs of stroke and cannot be ruled out as the primary cause of mild cognitive impairment without the prescriber's clinical progress notes. Lastly, the submitted evidence does not contain verification of clinical trial data specific to the enrollee.In addition, the submitted evidence supports Aduhelm intravenous infusion is administered to the enrollee at Memorial Hospital in Chattanooga, TN, not at home. The drugs administered intravenously are furnished Incident To a physicians service and are excluded from Medicare Part D coverage. Therefore, the intravenous infusion of Aduhelm is excluded from Part D coverage.