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

At issue is a tiering exception request for Trelegy Ellipta 100/62.5 microgram blister pack with inhalation device. 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 available documentation.Trelegy Ellipta is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no 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 requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Buprenorphine 2 milligram sublingual tablet to treat chronic pain, allodynia, schizoaffective disorder, Parkinsonism, and seizure disorder. 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 reviewed all available documentation.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The noted conditions are off-label uses for the requested drug. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these conditions. Therefore, the drug is being prescribed for non-medically accepted indications.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 coverage for Pregabalin 100 milligram capsule to treat partial onset seizures. 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 reviewed all available documentation.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. There is insufficient documentation available to confirm that the plans requirements for coverage have been satisfied or to support the medical necessity for an exception to the plans prior authorization requirements, as no medical records have been submitted for review. 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 tiering exception request for Anoro Ellipta 62.5/25 microgram blister pack with inhalation device to treat chronic obstructive pulmonary disease. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Anoro Ellipta is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no 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 requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Modafinil 200 milligram tablet to treat cancer-related fatigue. 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 reviewed all available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication.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 coverage for Klonopin 1 milligram tablet to treat generalized anxiety disorder. 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 reviewed all available documentation.The requested drug is not on the plans formulary. To grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed or must be deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale, with supporting medical records, as to why the alternative drug on the plans formulary to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Additionally, the submitted documentation does not include any medical records to confirm that the enrollee has tried and failed the formulary alternative drug. Therefore, the formulary exception requirements have not been met. 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 coverage for Dupixent 300 milligram per 2 milliliter solution pen injectors to treat chronic idiopathic urticaria. 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 reviewed all available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication.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 coverage for Tradjenta 5 milligram tablet to treat type 2 diabetes mellitus with chronic kidney disease. 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 reviewed all available documentation.The plan has a step therapy requirement that must be met before coverage of this drug will be provided. The submitted documentation does not support that the plans step therapy requirement has 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 coverage for Crestor 5 milligram tablet to treat the enrollee's condition . 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 reviewed all available documentation.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The submitted documentation does not include medical records or evidence of a prescribed diagnosis. This information was requested by the Part D plan with no response from the prescriber. The documentation submitted at reconsideration also does not include medical records or evidence of a prescribed diagnosis. As such, there is insufficient documentation available to establish that the requested drug has been prescribed for a medically accepted indication.The request for formulary and duplicate therapy exceptions cannot be reviewed because the requested drug was not prescribed for a medically accepted indication.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 coverage for Testosterone Cypionate 200 milligram per milliliter solution to treat hypogonadism. 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 reviewed all available documentation.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. Furthermore, the documentation does not support the medical necessity for an exception to the plans prior authorization requirements.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 coverage for Mycophenolate 500 milligram tablet to treat interstitial lung disease from rheumatoid arthritis. 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 reviewed all available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication.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 coverage for Fosfomycin 3 gram sachet to a urinary tract infection. 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 reviewed all available documentation.For the drug at issue to be covered under Medicare Part D, the manufacturer of the drug must participate in the Medicare Coverage Gap Discount Program. The manufacturer of this drug is not participating in the program. Therefore, the requested drug is excluded from Medicare Part D coverage.This decision does not address the medical necessity 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 coverage for Lidocaine/Prilocaine 2.5 percent cream for pain control, topical anesthesia for dialysis access. 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 reviewed all available documentation. Additionally, we researched Medicare systems.Medicare systems show that the enrollee has end stage renal disease (ESRD) coverage and is currently receiving dialysis. Drugs used for dialysis-related purposes for enrollees with end stage renal disease coverage who are receiving dialysis would be covered under Medicare Part B. Medicare rules state that any drug available for coverage under Medicare Part B cannot be covered under Part D. Therefore, the requested drug is not eligible for Medicare Part D coverage.This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Favorable

At issue is coverage for Nurtec 75 milligram oral disintegrating tablet with a quantity of 16 per 30 days for migraine prevention. 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 reviewed all available documentation.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation supports that all of the plans requirements for coverage have been satisfied. Specifically, the medical records show the enrollee has tried and failed Amitriptyline in the past, has 3-4 headaches a week, and is taking the other similar medication, Ubrelvy, for acute migraines. The medical records show the requested drug is for prevention of migraines and dosing is recommended at 75 milligram every other day. Therefore, the plans prior authorization requirements have been met and coverage for the drug is supported.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is coverage for Tyvaso 64 microgram dry powder inhaler maintenance kit to treat pulmonary hypertension who group 3 and interstitial lung disease. 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 reviewed all available documentation.The requested drug is not on the plans formulary. To grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed or must be deemed contraindicated. The prescriber has provided patient-specific clinical rationale as to why the alternative drugs on the plans formulary to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Specifically, Prescriber submitted records on appeal. The indication for Tyvaso 64 microgram dry powder inhalation therapy for Pulmonary hypertension Who group 3 with interstitial lung disease is the only available form for treatment of condition. Micromedex and Lexicomp also indicate the inhalation form to be Tyvaso. Therefore, a formulary exception is supported in this case.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Incruse Ellipta 62.5 micrograms per actuation inhaler to treat severe persistent asthma. 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 reviewed all available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication. As this drug is not eligible for Part D coverage, it is ineligible for consideration for a formulary exception.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 coverage for Xembify 10 gram per 50 milliliter solution to treat nonfamilial hypogammaglobulinemia (D80.1) and/or selective deficiency of immunoglobulin G (IgG) subclasses (D80.3). 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 reviewed all available documentation.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The Medicare approved compendia do not contain any citations to support the use of the requested drug for the treatment of nonfamilial hypogammaglobulinemia (D80.1). This diagnosis is not sufficient to determine the medical necessity for the drug as it does not clarify the underlying cause of the enrollees hypogammaglobulinemia. The diagnosis just indicates that the hypogammaglobulinemia is not due to a primary (familial/genetic) immune deficiency disorder. Furthermore, it should be noted that the only indication for the brand drug, Xembify, noted in the Medicare approved compendia and the Food and Drug Administration (FDA) labeling for the drug is for the treatment of primary immune deficiency disorders. Therefore, the use of the requested drug for the treatment of nonfamilial (secondary/non-genetic) hypogammaglobulinemia (D80.1) is not a medically accepted indication for the drug. The diagnosis of selective deficiency of immunoglobulin G (IgG) subclasses is a primary immune deficiency disorder. The administration of intravenous and/or subcutaneous immune globulin therapy for the treatment of a primary immune deficiency disorder would be covered under Medicare Part B. Medicare rules state that any drug available for coverage under Medicare Part B cannot be covered under Part D. Therefore, the use of the requested drug for the treatment of selective deficiency of immunoglobulin G (IgG) subclasses is not eligible for Medicare Part D coverage.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage for either diagnosis. If the drug is being prescribed to treat selective deficiency of immunoglobulin G (IgG) subclasses, please submit the request for coverage through Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Pregabalin 150 milligram capsule to treat essential tremor. 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 reviewed all available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication.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 tiering exception request for Gemtesa 75 milligram tablet to treat mixed incontinence. 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 available documentation.Gemtesa is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no 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 requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Deferiprone 500 milligram tablet to treat superficial siderosis of central nervous system. 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 reviewed all available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication.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 coverage for Cyclobenzaprine Hydrochloride 5 milligram tablet. 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 reviewed all available documentation.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The diagnoses initially provided to the plan for the requested drug were chronic back pain and/or skeletal muscle spasm due to a chronic musculoskeletal condition. However, the noted conditions are off-label uses for the requested drug. As outlined in the Medicare approved compendia and the Food and Drug Administration (FDA) labeling for the drug, FLEXERIL [Cyclobenzaprine Hydrochloride] is indicated as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions. FLEXERIL should be used only for short periods (up to two or three weeks) because adequate evidence of effectiveness for more prolonged use is not available.At reconsideration, it has now been noted that the requested drug has also been prescribed to treat acute muscle spasm. However, this diagnosis was not initially provided to the plan. Furthermore, no medical records have been submitted to validate this additional diagnosis. Therefore, due to the conflicting information provided and a lack of supporting medical records to confirm that the drug was prescribed to treat muscle spasm due to an acute musculoskeletal condition, it cannot be established that the requested drug has been prescribed for a medically accepted indication.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 coverage for Modafinil 100 milligram tablet. 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 reviewed all available documentation.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The diagnoses initially provided to the plan for the requested drug were excessive daytime sleepiness and/or other hypersomnia. However, the noted conditions are off-label uses for the requested drug. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these conditions. At reconsideration, a new diagnosis of excessive daytime sleepiness associated with obstructive sleep apnea has been noted. However, this diagnosis was not initially provided to the plan. Furthermore, no medical records (progress notes/sleep study results) have been submitted to validate this additional diagnosis. Therefore, due to the conflicting information provided and a lack of supporting medical records to confirm that the enrollee has excessive daytime sleepiness that is associated with a confirmed diagnosis of obstructive sleep apnea, it cannot be established that the requested drug has been prescribed for a medically accepted indication.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.