Persius/hicric huggingface dataset:
Appeal type: Prescription Drug
Decision: Partially 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 and provide reimbursement for Metoprolol Tartrate 6.25 mg, Furosemide 20 mg, Escitalopram 5 mg, Famotidine 20 mg, Atorvastatin 10 mg and Gabapentin 100 mg, and Vitamin D3, Vitamin B12, Acetaminophen 325 mg, Docusate Sodium 100 mg, Aspirin 81 mg and Multi Vitamin received while the patient was at the hospital.Metoprolol Tartrate 6.25 mg, Furosemide 20 mg, Escitalopram 5 mg, Famotidine 20 mg, Atorvastatin 10 mg and Gabapentin 100 mg:The Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. In this case, the record shows that the patient was at the hospital. The patient received Metoprolol Tartrate 6.25 mg, Furosemide 20 mg, Escitalopram 5 mg, Famotidine 20 mg, Atorvastatin 10 mg and Gabapentin 100 mg, for a medical emergency or urgent care. You submitted a request for reimbursement along with proof of payment of the self-administered drugs listed on the bill. The Plan's out-of-network coverage rules were followed. Therefore, our decision is the Plan is required to process the claim for Metoprolol Tartrate 6.25 mg, Furosemide 20 mg, Escitalopram 5 mg, Famotidine 20 mg, Atorvastatin 10 mg and Gabapentin 100 mg received while the patient was at the hospital.Vitamin D3 and Vitamin B12:Medicare law excludes certain drugs from Part D coverage. Vitamin D3 and Vitamin B12 are two of those excluded drugs because they are a prescription vitamin and mineral product. The record submitted by the Plan does not indicate that they provide supplemental coverage for Vitamin D3 and Vitamin B12. Therefore, the Plan is not required to cover Vitamin D3 and Vitamin B12 received while the patient was at the hospital.Acetaminophen 325 mg, Docusate Sodium 100 mg, Aspirin 81 mg and Multi Vitamin:Medicare Part D does not cover non-prescription drugs. We checked FDA approved sources for the drugs classifications or determined from other available resources that the drugs are a non-prescription or OTC drugs. Therefore, Aspirin EC 81 mg, received while the patient was at the hospital are not eligible for Part D coverage and the Plan is not required to cover or provide reimbursement for them under the Part D benefit. Information in the case record indicates that the enrollee was a patient when they received these drugs. As such, the enrollee was not in a position to obtain the drugs that had been previously filled at a network pharmacy, nor were they able to obtain prior authorization or off-formulary exception review. Since this was a one-time emergency stay, the Plan should provide an exception to their normal coverage rules.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Diclofenac Sodium 3% Gel. 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 Diclofenac Sodium 3% Gel.The drug is requested to treat osteoarthritis of multiple joints, 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 Diclofenac Sodium 3% Gel 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 Diclofenac Sodium 3% Gel. 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: Unfavorable

You asked the Plan to cover Otezla, 30 mg tablet. 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 Otezla, 30 mg tablet.Otezla, 30 mg tablet is requested to treat plaque psoriasis. For coverage under the prescription drug benefit, Medicare requires that the drug prescribed be used for a medically accepted indication. Our Physician Reviewer found that the Medicare-approved resources do contain citations to support the use of the requested drug for treatment of the noted condition. Therefore, the requested drug is being prescribed for a medically accepted indication.The enrollee does not satisfy the Plan's coverage criteria. The prescriber has not sufficiently addressed the Plan's coverage criteria and/or 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. Our Physician's opinion is that neither prior authorization nor prior authorization exception criteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. A Plan must grant an exception to prior approval rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on the available documentation, our Physician Reviewer's opinion is that an exception to prior approval criteria is not met. Therefore, the Plan is not required to cover Otezla, 30 mg tablet.
Appeal type: Prescription Drug
Decision: Partially Favorable

You asked the Plan to cover Abiraterone Acetate and Prednisone. The Plan did not grant this request. We received this case to conduct an independent review.Abiraterone Acetate:We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Zytiga (Abiraterone acetate) 250 mg; 120 per 30 days. The drug is requested to treat metastatic castration resistant prostate cancer. The enrollee is a 74 year old man with metastatic prostate cancer involving bones. He has been treated with Lupron and Casodex. Due to rising PSA levels, he was switched to Lupron and Nubeqa. Again his PSA is rising to 14.2 in 6/20 form 6.37 in December 2019 despite increasing doses of Nubeqa. You originally requested Zytiga to be given with Lupron and Eplerenone. At the time of the appeal you changed the plan to give the drug with Prednisone and Lupron. A copy of a prescription for the Prednisone is included in the submitted documents. There are contradictory statements of whether the enrollee has castration resistant or castration sensitive metastatic prostate cancer. The rising PSA on Lupron and Casodex and on Lupron and Nubeqa indicates that his cancer is not responding to androgen deprivation therapy (ADT) and is therefore castration resistant.Per the FDA website, Zytiga (Abiraterone acetate) is indicated in combination with prednisone for the treatment of patients with - Metastatic castration-resistant prostate cancer (CRPC) and - Metastatic high-risk castration-sensitive prostate cancer (CSPC). The NCCN compendium also recommend that ADT should be continued. The enrollee will continue to be on Lupron which is a type of ADT.The enrollee has castration resistant metastatic prostate cancer. The drug will be given in combination with Prednisone. Therefore the requested use is a medically accepted use. The plan's prior authorization criteria are met.For coverage under the prescription drug benefit, Medicare requires that the drug prescribed be used for a medically accepted indication. Our Physician Reviewer found that the Medicare-approved resources do contain citations to support the use of the requested drug for treatment of the noted condition. Therefore, the requested drug is being prescribed for a medically accepted indication. The enrollee satisfies the Plan's coverage criteria. Our Physician Reviewer's opinion is that prior authorization criteria are met.Prednisone:We are dismissing the request for Prednisone. We received your letter asking for an appeal of the Plan's unfavorable determination for Prednisone. Medicare rules do not allow us to review this case until you have completed the appeal process with the Plan. You may request a Reconsideration appeal with us after the Plan issues an unfavorable Redetermination. You may wish to submit this request to the Plan at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Hydroxypropyl Methylcellulose-Lactose Monohydrate-Hydrocodone Bitartrate Compound. The Plan did not grant this request. We received this case to conduct an independent review.Medicare Part D does not cover drugs that are not FDA approved for both safety and effectiveness. We determined that Hydroxypropyl Methylcellulose-Lactose Monohydrate-Hydrocodone Bitartrate Compound is not FDA approved for both safety and effectiveness by checking FDA sources. Therefore, the Plan is not required to cover Hydroxypropyl Methylcellulose-Lactose Monohydrate-Hydrocodone Bitartrate Compound. 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 provide a tiering exception for Rinvoq. The Plan did not grant this request. We received this case to conduct an independent review.If a Plan maintains a specialty tier, the Plan may design its exception process so that drugs placed in the specialty tier are not eligible for a tiering exception. Rinvoq is in the specialty tier. The record indicates the Plan has chosen to exclude the specialty tier from the tiering exception process. Therefore, the Plan is not required to provide a tiering exception for Rinvoq.
Appeal type: Prescription Drug
Decision: Partially Favorable

You asked the Plan to cover Azathioprine and Cyclosporine. The Plan did not grant this request. We received this case to conduct an independent review.The case record indicates that Azathioprine is needed for a kidney transplant performed. In this case, we sent a request for additional information to the Part D Plan. We requested the evidence that the Plan used to determine that Medicare paid for the transplant performed. The Plan responded to our request, however the Plan failed to provide claims data that supports that Medicare paid for the transplant in question. Based on the available information we cannot verify that coverage would be available for the requested drug under Medicare Part B. Therefore we asked our Physician Reviewer to determine if other Medicare Part D coverage criteria are met.Azathioprine:We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Azathioprine 50 mg. The drug is requested to treat Renal transplant rejection, Adjunct; Prophylaxis. Based on the information provided, the drug would be eligible for coverage under Part D for the enrollee's condition. The enrollee satisfies the Plan's coverage criteria. Our Physician Reviewer's opinion is that prior authorization criteria are met.Cyclosporine:We are dismissing the request for Cyclosporine. We received your letter asking for an appeal of the Plan's unfavorable determination for Cyclosporine. Medicare rules do not allow us to review this case until you have completed the appeal process with the Plan. You may request a Reconsideration appeal with us after the Plan issues an unfavorable Redetermination. You may wish to submit this request to the Plan at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Mycophenolate Mofetil, 500 mg tablet. 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 tablet.The drug is requested to treat interstitial pulmonary disease, unspecified/non-specific interstitial pneumonitis, 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 Mycophenolate Mofetil, 500 mg tablet 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, 500 mg tablet. 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: Unfavorable

You asked the Plan to cover Modafinil. 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 Modafinil 100 mg tablet. The drug is requested to treat cognitive decline, daytime sleepiness andtremor, which are off-label (non-FDA approved) uses. The Medicare-approved compendia do not containany citations to support the use of the requested drug, as prescribed, for treatment of the noted conditions.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. Of note the diagnosisof narcolepsy was added at the reconsideration level. The provided records did not include narcolepsy inthe patient's history of present illness or past medical history or in the assessment or plan. A notation wasmade in the record that the patient did not get sleep studies done. A polysomnogram and a multiple sleeplatency test would generally be needed to make the diagnosis of narcolepsy. Therefore, the requested drugis not eligible for coverage under Medicare Part D for the noted conditions.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 Modafinil 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 Modafinil.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 provide a tiering exception for Humulin Kwikpen 70/30. The Plan did not grant thisrequest. 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 a tiering exception for Humulin Kwikpen 70/30.The drug is requested to treat the enrollee's condition. The drug is a Brand drug on Tier 3 of the Plan'sformulary. The prescriber does not state why all available lower tier alternatives on the Plan's formulary totreat the enrollee's condition (1) would not be as effective for the enrollee as the requested drug and/or (2)would have adverse effects for the enrollee. Therefore, an exception to these criteria is not supported. OurPhysician 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 Humulin Kwikpen70/30.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Gammagard. 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 Gammagard 10% solution. The drug is requested to treat progressive scleromyxedema, which is an offlabel(non-FDA approved) use. The Medicare-approved compendia do not contain any citations to supportthe use of the requested drug, as prescribed, for treatment of the noted condition. Therefore, the requesteddrug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, anexceptions request based on medical necessity cannot be considered because the requested drug, asprescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is noteligible 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 Gammagard for the diagnosed condition. As a result, the drugis not being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannotbe covered 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 Gammagard.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: Favorable

You asked the Plan to cover Praluent. The Plan did not grant this request. We received this case to conductan independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Praluent 75 mg/mL 2/28. The drug is requested to treat hyperlipidemia and coronary artery disease withstent. Additional medical information was requested by the Part D QIC. The prescribing physician wasasked to address the Plan's prior authorization criteria. The prescriber states that the request is for initialtherapy with Praluent and not for reauthorization. The enrollee is intolerant of statins due to myalgias. Theenrollee had a pretreatment LDL of 123 mg/dL. The enrollee satisfies the Plan's coverage criteria. OurPhysician Reviewer's opinion is that prior authorization criteria are met.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 aremet. Therefore, our decision is the Plan is required to cover Praluent.Please note that if the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The health plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will notify you in writing that the case is being reviewed again and the outcome of the reopening.