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

At issue is Remicade 100 milligram solution prescribed for Crohns disease of the small intestines. 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 prescriber has prescribed Remicade 100 milligram solution to treat Crohns disease. 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 prescriber does not submit medical evidence as to why all other alternatives on the plans formulary would not work.A physician reviewed your appeal and determined that the plan is not required to cover Remicade.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a formulary exception request for Nurtec 75 milligram oral disintegrating tablets prescribed to treat an enrollee with acute migraine headaches. The Part D plan denied the appeal 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 medical records show the physician prescribed Nurtec 75 milligram oral disintegrating tablets to treat acute migraine headaches. Micromedex, a Medicare approved compendium shows Nurtec is indicated for the acute treatment of migraine with or without aura in adults. The medical records show that the enrollee cannot take other drugs on the plans formulary for the indicated condition. The prescriber indicates the enrollee has coronary artery disease that would be a contraindication for the available formulary alternatives drugs. In addition, the formulary alternative drugs classified as prophylactic do not apply since the requested drug is prescribed for acute migraine attack. The formulary alternative drugs classified as ergot alkaloids have ischemic heart disease as a contraindication. Therefore, the documentation supports the formulary exception request.A physician reviewed your appeal and determined that an exception can be granted to the requested drug. Therefore, the plan is required to cover Nurtec 75 milligram oral disintegrating tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xtandi 40-milligram capsule to treat malignant neoplasm of prostate. 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.Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has 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 Enbrel Sureclick 50 milligram/milliliter pen injector prescribed for the enrollees condition. 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

At issue is Repatha Sureclick 140 milligram/milliliter solution auto-injector prescribed as directed for coronary artery disease, peripheral vascular disease, and high risk of events for a cardiac event. 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 drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested compounded drug Mesalamine powder prescribed for the treatment of Crohns disease. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.We determined that the plan is not required to cover the Mesalamine powder. According to Medicare rules, drugs that fall into the category of bulk powders do not meet the definition of a Part D drug. The Mesalamine powder is considered a bulk powder and therefore, is excluded from coverage under Part D. There is no evidence that the plan offers supplemental benefits for this drug. 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 a tiering exception request for Viberzi 75-milligram tablet to treat an unspecified diagnosis. 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.This drug is being provided by the plan at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules.Our physician reviewer's opinion is that Specialty tier drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dronabinol 2.5 milligram capsules prescribed to treat an enrollee with nausea and vomiting related to gastroparesis. The Part D plan denied the appeal 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.Upon redetermination, the Part D plan reviewed the appeal request for prior authorization and utilization management (quantity limitations). The Part D plan denied the request stating the provided diagnosis was not a medically accepted indication and the utilization management requirement was not satisfied. The appeal request is for Dronabinol 2.5 milligram capsules to treat nausea and vomiting related to gastroparesis. 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. The drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. In addition, the utilization management will not be reviewed since the QIC is not allowing Medicare Part D coverage for the requested drug.A physician reviewed the appeal and determined that the plan is not required to cover Dronabinol 2.5 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq 25 milligram extended-release 24-hour tablets. The Part D plan denied the appeal 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.Myrbetriq is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type to treat the noted condition 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 your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sandostatin LAR Depot Kit 20-milligram Intramuscular Injection to treat iron deficiency anemia secondary to blood loss. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tremfya 100 milligram/milliliter injection prescribed as directed for active psoriatic arthritis. 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 drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Tremfya.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Colestipol micronized 1 gram tablet prescribed for non-infective gastroenteritis and colitis, post cholecystectomy syndrome, and bile enteritis. 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 Colestipol was prescribed for non-infective gastroenteritis and colitis, post cholecystectomy syndrome, and bile enteritis. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. Since the drug is not eligible for coverage under Part D, the plans tiering exception requirements are not applicable to this review. A physician reviewed the appeal and determined that the plan is not required to cover Colestipol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tamoxifen 20 milligram tablets 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. Tamoxifen is a generic drug on Tier 2 of the plans formulary. There are no generic 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 Actemra 162 milligram/0.9 milliliter injection solution prescribed for polymyalgia rheumatica. 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 submitted documentation shows the prescriber ordered Actemra for polymyalgia rheumatica. The Medicare approved compendia do not support the use of this biologic for the enrollees condition. A physician reviewed the appeal and determined that the plan is not required to cover Actemra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine Hydrochloride 5 milligram tablet prescribed for chronic pain management. 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 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 medical records indicate that Cyclobenzaprine Hydrochloride 5 milligram tablet is prescribed for neck, low back, and leg pain. The enrollee is being seen at a pain management center for chronic pain. However, Medicare approved compendia does not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synthroid 150 microgram tablets 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. Synthroid 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 Freestyle Libre 14 day sensor prescribed to monitor an enrollee with diabetes. The Part D plan denied the appeal 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.Supplies for testing and monitoring blood glucose levels are not considered Part D drugs and may be covered under the Medicare Part B Durable Medical Equipment benefit. We have determined that the plan is not required to cover Freestyle Libre 14-day sensor. The decision does not address medical necessity of the requested item. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pulmozyme 1 milligram/milliliter nebulizer solution prescribed for bronchiectasis, uncomplicated, and unspecified asthma, uncomplicated. 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 submitted documentation shows the prescriber ordered Pulmozyme for bronchiectasis, uncomplicated, and unspecified asthma, uncomplicated. The Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed the appeal and determined that the plan is not required to cover Pulmozyme.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ondansetron 8 milligram disintegrating tablets prescribed for nausea and vomiting due to hyponatremia, irritable bowel syndrome, and gastroesophageal reflux disease. 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 submitted documentation shows the prescriber ordered Ondansetron for nausea and vomiting due to hyponatremia, irritable bowel syndrome, and gastroesophageal reflux disease. The Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed the appeal and determined that the plan is not required to cover Ondansetron.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ingrezza 40 milligram tablets prescribed as directed for tardive dyskinesia. 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 drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Ingrezza.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium 3% gel prescribed 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 your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The medical records show Diclofenac Sodium 3% gel is prescribed for osteoarthritis. Medicare approved compendia do not support the use of this drug for your condition.  A physician reviewed your appeal and determined that the plan is not required to cover Diclofenac Sodium 3% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Caplyta 42 milligram capsule prescribed for bipolar disorder. 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 the prescriber requests Caplyta to treat bipolar disorder. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Caplyta.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Repatha Pushtronex 420 milligram/3.5 milliliter prescribed as directed for other hyperlipidemia, and other specified health status. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Repatha Pushtronex to treat your other hyperlipidemia, and other specified health status. However, the use of the requested drug to treat the provided diagnosis is an off-label use.  The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Repatha Pushtronex.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Spiriva Respimat 2.5 microgram/1 actuation inhaler prescribed for chronic obstructive pulmonary disease. 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 medical records indicate the prescriber ordered Spiriva Respimat 2.5 microgram/1 actuation inhaler for chronic obstructive pulmonary disease. The prescriber ordered a quantity of drug, 12 grams/30 days, which is greater than the plans allowance of 4 grams/30 days. The quantity of drug ordered by the prescriber exceeds the Food and Drug Administration-approved dosing regimen. The Medicare approved compendia do not support the use of the drug for greater than the Food and Drug Administration-approved dosing regimen. The medical records do not support why an exception to the plans quantity limit is medically necessary. A physician reviewed the appeal and determined that the plan is not required to cover the Spiriva Respimat, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Normal Saline Flush 0.9% syringe prescribed for unknown diagnosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.We determined that the Part D plan is not required to cover the Normal Saline Flush 0.9% syringe. According to Medicare rules, medical devices are excluded from coverage under Part D. The Normal Saline Flush 0.9% syringe is considered a medical device. Therefore, it is excluded from coverage under the Part D benefit. However, Normal Saline Flush 0.9% syringe may be covered under Medicare Part B, as a medical benefit. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.