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

At issue is a request for coverage of Kisqali 200 milligram tablets prescribed for the treatment of metastatic breast cancer. 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. The plan has prior authorization requirements that must be met before coverage of this medication will be approved. The submitted medical records do not support that the plans coverage criteria have been satisfied. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Ciclopirox 8% solution prescribed for onychomycosis of the toenails. 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. We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support all formulary alternatives were tried and failed. However, we did not receive the requested information.The documentation medical records submitted did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Ciclopirox.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Xtandi 40 milligram tablets. The Part D plan denied the request because there was insufficient documentation to determine if the drug was being requested for a medically accepted indication. 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 prescriber statement of medical necessity and supporting medical records were requested from the prescriber. The prescriber responded and submitted the requested documentation.The newly submitted medical records indicate that Xtandi had been prescribed for the treatment of non-metastatic castrate-resistant prostate cancer, which is a medically accepted indication for Xtandi outlined in the Medicare approved compendia. The medical records also support that the plans prior authorization requirements have been met, as it is noted that the enrollee will be taking Xtandi in combination with androgen deprivation therapy, specifically the gonadotropin releasing hormone (GnRH) analog, Lupron. The plans quantity limit for Xtandi is 120 tablets per 30 days. The prescriber is requesting a daily dosage of 160 milligrams, which would be four 40 milligram tablets per day, or 120 tablets per 30 days. Therefore, the newly submitted documentation supports the medication is being prescribed for a medically accepted indication, the plans coverage requirements have been met, and the quantity limit has not been exceeded. As such, coverage for the drug can be allowed. A physician reviewed the appeal and determined that the plan is required to cover the Xtandi.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Metronidazole 1% gel prescribed for unspecified rosacea. 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. We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support all formulary alternatives were tried and failed. However, we did not receive the requested information.The documentation submitted did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Metronidazole.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Idhifa 100 milligram tablets prescribed for malignant neoplasm of long bones of left lower limb, secondary neoplasm of unspecified lung. 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 Idhifa for malignant neoplasm of long bones of left lower limb, secondary neoplasm of unspecified lung. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. There were no Medicare approved journal articles submitted to support the use of Idhifa in 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 Xifaxan 550 milligram tablets prescribed for the enrollees condition. 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.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the enrollee met the plans prior authorization coverage criteria. However, we did not receive the requested information.The submitted documentation does not contain medical records or evidence of a prescribed diagnosis. As it cannot be determined that the drug was 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 Lumakras 120 milligram tablets prescribed for metastatic pancreatic cancer. 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 Lumakras for metastatic pancreatic cancer. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. There were no Medicare approved journal articles submitted to support the use of Lumakras in 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 Calcitriol 0.25 microgram capsules prescribed for hypocalcemia. 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 drug at issue is being used for dialysis-related services. Dialysis-related medications are included in the bundled payment that Medicare pays to dialysis centers under Medicare Part B. This is eligible for coverage under Part B. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of the 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 Sodium Chloride 0.9% irrigation solution prescribed for bladder-neck obstruction. 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 record shows Sodium Chloride was prescribed to flush a suprapubic catheter. However, this drug may be eligible for coverage under Medicare Part B. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipmentWe determined that the Part D plan is not required to cover the Sodium Chloride. Please consider submitting this request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dexcom G6 Sensor prescribed for type 2 diabetes mellitus. The Part D plan denied the request. We performed and 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.We determined that the plan is not required to cover Dexcom G6 Sensor because it is a medical device. Medical devices are excluded from coverage. The plan does not offer supplemental (additional) coverage for this item. If the enrollee purchased items that are excluded, the enrollee must pay for the items. This decision does not address the medical necessity or appropriateness of the item. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Procrit 10000 units/milliliter solution prescribed for anemia in chronic kidney disease. 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 on hand does not indicate that the enrollee satisfies the plan's prior authorization 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 a prior authorization request for Vyndamax 61 milligram capsules prescribed for cardiomyopathy of hereditary transthyretin-mediated amyloidosis. 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 on hand does not indicate that the enrollee satisfies the plan's prior authorization 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 a request for Corlanor 7.5 milligram tablet prescribed for postural orthostatic tachycardia syndrome. 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 Corlanor was prescribed to treat postural orthostatic tachycardia syndrome However, the Medicare approved compendia do not support the use of this drug for the enrollee's condition. A physician reviewed your appeal and determined that the plan is not required to cover Corlanor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Neudexta 20-10 milligram capsules prescribed for pseudobulbar affect. 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 records submitted at the reconsideration level. The medical records show Neudexta was prescribed for pseudobulbar affect. 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 your appeal and determined that the plan is not required to Neudexta. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Zolpidem Tartrate 10 milligram tablets prescribed for insomnia. 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 on hand does not indicate that the enrollee satisfies the plan's prior authorization 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 a prior authorization request for Prolia 60 milligram/milliliter injection prescribed for osteoporosis in a male enrollee with a history of prostate cancer. 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. We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the enrollee met the plans prior authorization coverage criteria. However, we did not receive the requested information.The documentation on hand does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.A physician reviewed the appeal and determined that the requested biologic is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine Hydrochloride-Naloxone Hydrochloride 8 milligram-2 milligram sublingual films prescribed for polycystic ovarian syndrome, chronic pain syndrome, mixed connective tissue disease, and chronic low back pain. 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 Buprenorphine Hydrochloride-Naloxone Hydrochloride sublingual films for polycystic ovarian syndrome, chronic pain syndrome, mixed connective tissue disease, and chronic low back pain. 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 Alprazolam 0.5 milligram tablets, 90 tablets per 15 days, prescribed for generalized anxiety 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. The amount of medication requested, 90 tablets per 15 days, exceeds the plans quantity limit for Alprazolam 0.5 milligram tablets, which is 150 tablets per 30 days, or 75 tablets per 15 days. During this review, a request was submitted to the prescriber to address the need to exceed the amount of medication allowed by the plan and to provide supporting medical records. A reply from the prescriber was not received. Therefore, an exception to the quantity limit criteria is not supported. A physician reviewed the appeal and determined that the plan is not required to cover 90 tablets per 15 days of the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Flector 1.3% patch prescribed for acute pain due to trauma. 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. 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 prescribers statement does not support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Flector patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aimovig 70 milligrams/milliliter auto injector prescribed for migraine headache prophylaxis. 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.Aimovig is a biologic on Tier 4 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 Lynparza 100 millligram tablet prescribed for breast cancer, stage IV, high grade ER/PR negative, HER2 positive. 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 Lynparza prescribed for breast cancer, stage IV, high grade ER/PR negative, HER2 positive. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Lynparza.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of compounded Budesonide nebulizer suspension, Gentamicin injectable solution, and Sodium Chloride irrigation solution to be used nasally, 10 milliliters in each nostril three times a day. 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 submitted to the plan indicates that the compounded Budesonide, Gentamicin, and Sodium Chloride has been prescribed for the treatment of chronic sinusitis. It has been noted at reconsideration that the drug is being used to treat a lung tumor. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of either 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 Methadone Hydrochloride 5 milligram tablets prescribed for 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 Methadone Hydrochloride for 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 Rivastigmine 4.6 milligram/24 hour patch prescribed for memory 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 submitted documentation indicates the prescriber originally ordered Rivastigmine for memory loss. The prescriber, on appeal, indicated the diagnosis should be dementia of the Alzheimers type. However, the progress notes submitted support the enrollee was assessed for memory loss and the memory disturbances were multifactorial in nature. 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 Livalo 2 milligram tablet prescribed for hyperlipidemia, unspecified. 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 and prescribers statement do not support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Livalo.