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

At issue is a formulary exception request for Gralise 600 milligram tablets prescribed for breakthrough migraine pain and restless leg syndrome. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates the prescriber ordered Gralise for breakthrough migraine pain and restless leg syndrome. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Hyoscyamine Sulfate 0.125 milligram sublingual tablets prescribed for the treatment of spastic colon. 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.Hyoscyamine Sulfate has not has not been found by the Food and Drug Administration to be safe and effective. Drugs not approved by the Food and Drug Administration are excluded from Part D coverage. We have determined that the Medicare Part D plan is not required to cover the requested drug. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Fenofibrate 120 milligram tablets prescribed for the treatment of pure hyperglyceridemia. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Fenofibrate 120 milligram tablets are not included in the plans formulary (list of covered drugs). Fenofibrate 134 mg capsules and Fenofibrate 145 mg, 160 mg, 48 mg, and 54 mg tablets are on the plan's formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Xifaxan 550 milligram tablets prescribed for hepatic encephalopathy and end-stage liver disease secondary to nonalcoholic steatohepatitis cirrhosis. 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. Xifaxan is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type to treat the noted conditions on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Basaglar KwikPen 100 units/milliliter prescribed as directed for diabetes. 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 Basaglar KwikPen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine Hydrochloride 10 milligram tablet prescribed for low back muscle spasms. 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 any information submitted at the reconsideration level. The prescriber indicates Cyclobenzaprine Hydrochloride 10 milligram tablet is prescribed to treat low back muscle spasms and the enrollee has been on this medication for years. However, the Medicare approved compendia do not support the use of this drug for this condition. It is to be used as an adjunct to treat skeletal muscle spasm associated with acute, painful musculoskeletal conditions and not indicated for long term use. 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 Xultophy 100/3.6 100 unit/1 milliliter-3.6 milligram/1 milliliter subcutaneous solution 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.Xultophy 100/3.6 is a biologic on Tier 3 of the plans formulary. There are no biologics of the same type on the lower cost sharing tiers. Therefore, this biologic is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Nubeqa 300 milligram tablets. The Part D plan denied the request for coverage. We received a reconsideration 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 documentation indicates that Nubeqa has been prescribed for the treatment of metastatic castration-resistant prostate cancer. However, 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. The documentation does not include any peer-reviewed, clinically relevant medical literature from an approved journal to support the use of the requested drug for the treatment of the noted condition. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare. 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.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Enspryng 120 milligram per milliliter prefilled subcutaneous injection syringe. 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. During this review, a statement of medical necessity and supporting medical records were requested from the prescriber. The prescriber responded and submitted the requested documentation. The documentation indicates that Enspryng has been prescribed for the treatment of anti-aquaporin-4 (AQP4) antibody positive neuromyelitis optica, which is a medically accepted indication for the use of Enspryng, as outlined in the Medicare approved compendia. However, Enspryng is not included on the plans formulary (list of covered drugs). The prescriber has addressed the formulary alternative, Mycophenolate Mofetil, and noted that Mycophenolate Mofetil is contraindicated in this enrollee, as Mycophenolate Mofetil would place the enrollee, who is already debilitated, at a higher risk for infection. Additionally, the prescriber has noted that Mycophenolate Mofetil would take months to become therapeutic and the enrollee is already experiencing advanced debility from a recent neuromyelitis optica attack and needs a fast-acting treatment. Therefore, the newly submitted medical records support that the medication is being used for a medically accepted indication. Additionally, the documentation supports a formulary exception in this case. A physician reviewed the appeal and determined that the formulary exception criteria have been met and that the plan is required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Tramadol ER 200 milligram extended release tablets prescribed for the treatment of chronic back and neck pain. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Tramadol ER is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives that are included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Dronabinol 5 milligram capsules. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The medical records indicate that Dronabinol has been prescribed for the treatment of post-surgical and cancer associated neuropathic throat pain and for anorexia and difficulty eating due to scar tissue at the anterior neck status post treatment for laryngeal cancer. 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 conditions. Therefore, the drug is being prescribed for non-medically accepted indications and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Verzenio 200 milligram tablet to treat well differentiated liposarcoma. 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 Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. There were no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Testosterone 1% (50 milligram/5 gram) gel prescribed for male hypogonadism. The Part D plan denied coverage.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 records submitted at the reconsideration level. The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records.  A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested prior authorization for Tymlos 3120 micrograms/1.56 milliliter prescribed as directed for a male with age-related osteoporosis without current pathological fracture and personal history of (healed) traumatic fracture. 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 Tymlos to treat your age-related osteoporosis without current pathological fracture and personal history of (healed) traumatic fracture in a male. 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 Tymlos.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ingrezza 80 milligram capsules prescribed for tardive dyskinesia. 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.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed the appeal and determined that the plan is not required to cover Ingrezza.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synthroid 88 microgram tablets prescribed to treat hypothyroidism. The Part D plan denied the appeal request for a tiering exception.The QIC received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Synthroid is a brand drug on Tier 3 of the plans formulary. The medical records do not support that all brand drugs available on lower tiers to treat the enrollees condition have been tried or deemed contraindicated. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Corlanor 5 milligram tablets prescribed to treat inappropriate sinus tachycardia. The Part D plan denied the appeal request.The QIC received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Upon redetermination, the Part D plan denied the appeal request stating that the plans prior authorization requirements were not satisfied for the diagnosis of heart failure. The documentation shows your doctor prescribed Corlanor 5 milligram tablets to treat inappropriate sinus tachycardia. The medical records provided fail to support the diagnosis of heart failure. 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 Corlanor 5 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine Hydrochloride 10 milligram tablets prescribed for muscle spasms due to a spinal injury and paraplegia. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates the prescriber ordered Cyclobenzaprine Hydrochloride for muscle spasms due to a spinal injury and paraplegia (chronic conditions). The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lenvima 10 milligram capsule to treat metastatic squamous cell carcinoma of the right tonsil. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. We received a reconsideration 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 Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rytary extended-release 48.75-195 milligram capsules. The Part D plan denied the appeal request for a tiering exception.The QIC received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Rytary is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Cresemba 186 milligram capsules. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation indicates that Cresemba has been prescribed for the treatment of pulmonary histoplasmosis and for antifungal prophylaxis, as the enrollee is receiving chemotherapy treatment for progressive pancreatic adenocarcinoma. 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 conditions. Therefore, the drug is being prescribed for non-medically accepted indications and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vraylar 1.5 milligram capsules prescribed to treat a mood disorder. The Part D plan denied the appeal request.The QIC received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows the doctor prescribed Vraylar 1.5 milligram capsules to treat a mood disorder. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition.  The prescriber was asked in the Reconsideration appeal to provide medical records.  No medical records were provided.A physician reviewed the appeal and determined that the plan is not required to cover Vraylar 1.5 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nucynta extended-release 150 milligram tablets prescribed to treat chronic lumbar and cervical pain along with bilateral hand, wrist, and knee pain. The Part D plan denied the appeal request.The QIC received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The prescriber indicates that several of the plans alternative formulary drugs could cause harm. The prescriber also indicates a couple of plans alternative formulary drugs were tried and helpful. In order to grant an exception for a drug not on the plans formulary, all alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the records do not support why all other drugs on the plans formulary would not work for the enrollee.A physician reviewed the appeal and determined that the plan is not required to cover Nucynta extended-release 150 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Evenity 105 milligram/1.17milliliter solution prefilled syringe prescribed as directed for postmenopausal osteoporosis. 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 Evenity.