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

You asked the Plan to cover Capecitabine. The Plan did not grant this request. We received this case toconduct an independent review.Medicare law defines those drugs that are eligible to be covered under the prescription drug benefit.Medicare law specifically excludes coverage for any drug for which payment would be available underParts A or B of Medicare for that individual. Medicare Part B coverage includes oral anti-cancer drugs thatare prescribed as anti-cancer chemotherapeutic agents providing they have the same active ingredients andare used for the same indications as anti-cancer chemotherapeutic agents which would be covered if theywere not self-administered and they were furnished incident to a physician's service as drugs andbiologicals.This coverage includes FDA approved prodrugs used as anti-cancer drugs. The oral anti-cancer drug mustbe used for the same anti-cancer chemotherapeutic indications, including unlabeled or off-label uses, asthe non-self-administrable form of the drug. A claim denied for the reason that the diagnosis does not fall inthe covered diagnosis section of the Policy Article, titled ICD-10 Codes that are Covered, will receive astatutory denial as non-covered, but may be covered at appeal if used for a medically accepted indication,as defined by Medicare law for oral anti-cancer chemotherapeutic agents.In this case the record shows that Capecitabine is being prescribed for a diagnosis of ICD-10 C23(Malignant neoplasm of gallbladder). Medicare Part B provides coverage for oral anti-cancer drugs whenused as anti-cancer chemotherapeutic agents. It appears Capecitabine may be eligible for coverage underMedicare Part B for the diagnosis provided in this case. Drugs which are eligible for Part B coverage areexcluded from Part D coverage by Medicare law. Therefore, our decision is that the Part D Plan is notrequired to cover Capecitabine.This decision does not concern the medical necessity or appropriateness of the requested drug. It onlyestablishes if payment can be made under the Medicare Part D benefit.You may wish to submit this request to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Hydromet. The Plan did not grant this request. We received this case to conduct an independent review.Medicare law excludes certain drugs from Part D coverage. Hydromet is one of those excluded drugs because it is a drug used for the symptomatic relief of coughs and colds. The record submitted by the Plan does not indicate that they provide supplemental coverage for Hydromet. Therefore, the Plan is not required to cover Hydromet. 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.
Appeal type: Prescription Drug
Decision: Favorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Rinvoq ER, 15 mg tablet as prescribed. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Rinvoq ER, 15 mg tablet.Rinvoq ER, 15 mg tablet is requested for treatment of rheumatoid arthritis. It is noted that the enrollee has failed Methotrexate and Hydroxychloroquine. The enrollee satisfies the Plan's coverage criteria. Our Physician Reviewer's opinion is that prior authorization criteria are met.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. A medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia. Our Physician Reviewer reviewed this file and determined that there are citations in the Medicare approved compendia that support the use of Rinvoq ER, 15 mg tablet as prescribed for the diagnosed condition. As a result, Rinvoq ER, 15 mg tablet as prescribed is being prescribed for a medically accepted indication as defined by Medicare law.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. Based on the available documentation, our Physician Reviewer's opinion is that prior approval criteria are met. Therefore, our decision is the Plan is required to cover Rinvoq ER, 15 mg tablet as prescribed.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Veltassa 8.4 gm. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Veltassa 8.4 gm.The drug is requested to treat hyperkalemia. The prescriber has not indicated why all alternatives required by the Plan would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exception criteria are not met.A Plan must grant an exception for a drug that is not on its formulary if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on a review of the available documentation, our Physician Reviewer's opinion is that formulary exception criteria are not met. Therefore, the Plan is not required to cover Veltassa 8.4 gm.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Mycophenolate Mofetil. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Mycophenolate Mofetil 500 mg.The drug is requested to treat myositis and interstitial lung disease-NSIP pattern, which is an off-label (non-FDA approved) use. The prescriber clarified the diagnoses in a letter dated 7/20/2020. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. A medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia. Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicare approved compendia that support the use of Mycophenolate Mofetil for the diagnosed condition. As a result, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be covered under the Medicare Part D benefit for this condition. An exceptions request based on medical necessity cannot be considered because this drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage for Mycophenolate Mofetil. This decision does not concern the medical necessity of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Esomeprazole Magnesium 40 mg capsule, 180 capsules per 90 days. The Plandid not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Esomeprazole Magnesium 40 mg capsule, 180 capsules per 90 days. The drug is requested to treatgastroesophageal reflux disease. Additional medical information was requested by the Part D QIC. Youwere asked to address the Plan's authorization criteria and to provide the enrollee's diagnosis. The Planlimits the amount of the drug to a 30 day supply. Guidance from the Centers for Medicare and MedicaidServices related to Coronavirus Disease 2019 states that Part D sponsors must suspend all quantity anddays' supply limits under 90 days for all covered Part D drugs other than such limits resulting from safetyedits. Therefore, an exception to the Plan's coverage criteria is medically necessary. Our PhysicianReviewer's opinion is that quantity limit exception criteria are met.Medicare rules allow a Part D Plan to manage its formulary by covering a limited quantity of certain drugs.A Plan must grant an exception if it determines that the requested dosage is medically reasonable and  necessary, consistent with the prescriber's statement. Based on a review of the available documentation, our Physician Reviewer's opinion is that an exception to the quantity limit criteria is met. Therefore, the Plan is required to cover the requested quantity of Esomeprazole Magnesium 40 mg capsule, 180 capsulesper 90 days.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide tiering exceptions for Premarin and Synthroid. The Plan did not grant this request. We received this case to conduct an independent review. We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for a tiering exception for Premarin and Synthroid. Premarin is requested to treat post hysterectomy state. Synthroid is requested to treat hypothyroidism. Premarin is on Tier 4 of the Plan's formulary. Synthroid is on Tier 3 of the Plan's formulary. There are no available lower tier brand drugs on the Plan's formulary to treat your conditions. Therefore, these drugs are not eligible for a tiering exception. Our Physician Reviewer's opinion is that tiering exception criteria are not met for Premarin or SynthroidMedicare rules permit a Plan to grant an exception to its tiering structure so long as there is a drug of the same type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) in a lower cost-sharing tier approved for treating the same condition that the higher cost-sharing tiered drug is being used to treat. Our Physician Reviewer's opinion is that tiering exception criteria are not met because there are no lower cost-sharing tiered drugs of the same type for treating your condition. Therefore, our decision is the Plan is not required to provide a tiering exception for Premarin and Synthroid.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to provide a tiering exception for Dofetilide. The Plan did not grant this request. Wereceived this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor a tiering exception for Dofetilide. The drug is requested to treat atrial fibrillation. The drug is aGENERIC drug on Tier 4 of the Plan's formulary. The prescriber does not state why all available lower tieralternatives on the Plan's formulary to treat your condition (1) would not be as effective for you as therequested drug and/or (2) would have adverse effects for you. Therefore, an exception to these criteria isnot supported. Our Physician Reviewer's opinion is that tiering exception criteria are not met.Medicare rules require a Plan to grant an exception to its tiering structure whenever it determines that thehigher cost-sharing tiered drug for treatment of the enrollee's condition is medically necessary consistentwith the prescriber's statement. Our Physician Reviewer's opinion is that tiering exception criteria are notmet. Therefore, our decision is the Plan is not required to provide a tiering exception for Dofetilide.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Rinvoq ER 15 mg in a 90 day supply. The Plan did not grant this request. Wereceived this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Rinvoq ER 15 mg 90 per 90 days. The drug is requested to treat rheumatoid arthritis. The Plan limitsthe amount of the drug to a recurring 30 day supply. Guidance from the Centers for Medicare and MedicaidServices related to Coronavirus Disease 2019 states that Part D sponsors must suspend all quantity anddays' supply limits under 90 days for all covered Part D drugs other than such limits resulting from safetyedits. Therefore, an exception to the Plan's coverage criteria is medically necessary. Our PhysicianReviewer's opinion is that quantity limit exception criteria are met.Medicare rules allow a Part D Plan to manage its formulary by covering a limited quantity of certain drugs.A Plan must grant an exception if it determines that the requested dosage is medically reasonable andnecessary, consistent with the prescriber's statement. Based on a review of the available documentation,our Physician Reviewer's opinion is that an exception to the quantity limit criteria is met. Therefore, thePlan is required to cover the requested quantity of Rinvoq ER 15 mg in a 90 day supply.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Dronabinol. The Plan did not grant this request. We received this case toconduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Dronabinol 2.5 mg cap. The drug is requested to treat nausea and vomiting in an enrollee with cysticfibrosis, status post lung transplants, renal failure, and malnutrition on enteral feeds, which is an off-label(non-FDA approved) use. The prescriber clarified the medical history in a letter dated 7/20/2020. Medicalrecords were provided to support these diagnoses. The Medicare-approved compendia do not contain anycitations to support the use of the requested drug, as prescribed, for treatment of the noted condition.Therefore, the requested drug is not being prescribed for a medically accepted indication as defined byMedicare law. As such, an exceptions request based on medical necessity cannot be considered because therequested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, therequested drug is not eligible for coverage under Medicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically acceptedindication. A medically accepted indication means a use that is approved by the FDA or a use that issupported by one or more citations in Medicare approved compendia.Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicareapproved compendia that support the use of Dronabinol for the diagnosed condition. As a result, the drug isnot being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot becovered under the Medicare Part D benefit for this condition. An exceptions request based on medicalnecessity cannot be considered because this drug, as prescribed, does not meet the definition of a MedicarePart D drug. Therefore, our decision is that the Plan is not required to provide coverage for Dronabinol.This decision does not concern the medical necessity of the requested drug. It only establishes if paymentcan be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Mycophenolate Mofetil, 500 mg tablet. The Plan did not grant this request. Wereceived this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Mycophenolate Mofetil, 500 mg tablet.The drug is requested to treat NSIP (nonspecific interstitial pneumonia) interstitial lung disease, which is anoff-label (non-FDA approved) use. The prescriber sent a letter dated 7/20/2020 clarifying the diagnosis.Medical records from date of service 7/2/2020 were provided which support this diagnosis. The Medicareapprovedcompendia do not contain any citations to support the use of the requested drug, as prescribed, fortreatment of the noted condition. Therefore, the requested drug is not being prescribed for a medicallyaccepted indication as defined by Medicare law. As such, an exceptions request based on medical necessitycannot be considered because the requested drug, as prescribed, does not meet the definition of a MedicarePart D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the notedcondition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically acceptedindication. A medically accepted indication means a use that is approved by the FDA or a use that issupported by one or more citations in Medicare approved compendia.Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicareapproved compendia that support the use of Mycophenolate Mofetil, 500 mg tablet for the diagnosedcondition. As a result, the drug is not being prescribed for a medically accepted indication as defined byMedicare law. As such, it cannot be covered under the Medicare Part D benefit for this condition. Anexceptions request based on medical necessity cannot be considered because this drug, as prescribed, doesnot meet the definition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required toprovide coverage for Mycophenolate Mofetil, 500 mg tablet.This decision does not concern the medical necessity of the requested drug. It only establishes if paymentcan be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Tadalafil, 5 mg tablet, 30 per 30 days. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Tadalafil, 5 mg tablet, 30/30.The drug is requested to treat male hypogonadism with erectile dysfunction. In the Reconsideration appeal dated 7/20/2020 the prescriber changed the diagnosis to benign prostatic hypertrophy. The provided medical records do not support that the requested drug is being prescribed to treat the diagnosis of benign prostatic hypertrophy. The provided records support the diagnosis of male hypogonadism and erectile dysfunction. Also note that the prescriber wrote in the appeal dated 7/16/2020, The patient has diagnosis of ED...The Tadalafil is being prescribed for ED...The patient has hx (sic) of hypogonadism, therefore he needs ED medication. Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not FDA approved, are excluded from coverage under Medicare Part D. Therefore the requested drug is excluded from coverage.Medicare law excludes certain drugs from Part D coverage. Tadalafil, 5 mg tablet, 30 per 30 days is one of those excluded drugs because it is a drug used to treat sexual or erectile dysfunction or sexual or erectile dysfunction drug used to treat a condition other than sexual or erectile dysfunction for which the drug has not been approved by the FDA. The record submitted by the Plan does not indicate that they provide supplemental coverage for Tadalafil, 5 mg tablet, 30 per 30 days. Therefore, the Plan is not required to cover Tadalafil, 5 mg tablet, 30 per 30 days. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover and provide reimbursement for Spravato 56 mg purchased March 12, 2020,March 24, 2020, April 1, 2020 and May 2, 2020 at an out of network pharmacy. The Plan did not grant thisrequest. We received this case to conduct an independent review.The Part D Plan covers prescriptions filled at an out-of-network pharmacy only in certain limitedcircumstances. In this case, the record shows you went to an out of network pharmacy. There is noexplanation given as to why you could not have gone to an in-network pharmacy. The Plan's out-ofnetworkcoverage rules were not followed. Therefore, our decision is the Plan is not required to providecoverage for Spravato 56 mg purchased March 12, 2020, March 24, 2020, April 1, 2020 and May 2, 2020at an out-of-network pharmacy.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Xeljanz, 5 mg tablet, 60 per 30 days. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Xeljanz, 5 mg tablet.The drug is requested to treat idiopathic urticaria, which is an off-label (non-FDA approved) use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. A medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia. Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicare approved compendia that support the use of Xeljanz, 5 mg tablet, 60 per 30 days for the diagnosed condition. As a result, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be covered under the Medicare Part D benefit for this condition. An exceptions request based on medical necessity cannot be considered because this drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage for Xeljanz, 5 mg tablet, 60 per 30 days. This decision does not concern the medical necessity of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.