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

At issue is Albuterol Sulfate 2.5-milligram/3-milliliter nebulizer solution to treat asthma. 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, including the case file from the plan, and any information submitted at the reconsideration level. Based on the information provided, we determined the drug may be eligible for coverage under Part B under Medicare rules.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 Odactra 12 standardized quality (SQ) house dust mite (HDM) sublingual tablets. The Part D plan denied the request for coverage because the drug was being prescribed for a non-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.The submitted medical records/progress notes indicate that Odactra has been prescribed for the treatment of allergic rhinitis, specifically animal (cat, dog) hair and dander and pollen. However, the Medicare approved compendia do not contain any citations to support the use of the Odactra for the treatment of the noted conditions. At reconsideration, the prescriber has indicated that the enrollee has perennial allergic rhinitis due to dust mites. However, the previously submitted medical records do not indicate the enrollee has allergic rhinitis due to dust mites. Additionally, no medical records have been submitted at reconsideration to support the additional diagnosis of perennial allergic rhinitis due to dust mites. Therefore, there is insufficient documentation to determine if the requested drug is being prescribed for a medically accepted indication. After the reconsideration review, the prescriber has submitted an allergen testing record that confirms the enrollee has an allergy to house dust mites. The use of Odactra in the treatment of allergic rhinitis due to house dust mites in individuals aged 18 through 65 years is a medically accepted indication outlined in the Medicare approved compendia. However, the enrollee is more than 65-years-old. As noted in the Medicare approved compendia, DRUGDEX, studies in geriatric patients have not been conducted with Allergenic Extract Standardized Mite. The safety and effectiveness of Odactra have not been established in persons older than 65 years. Since the enrollee is more than 65-years-old, the requested drug continues to be prescribed for a non-medically accepted indication. As such, the requested drug 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 Auryxia 1-gram (210-milligram ferric iron) tablet to treat hyperphosphatemia in an enrollee who has end stage renal disease and is currently undergoing dialysis. 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 documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The requested drug is not on the plans formulary. 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 documentation does not support why the alternative drugs provided on the plans formulary list would likely not be as effective for this diagnosis, and/or would likely cause adverse reactions or other harm.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 Octreotide Acetate 50-milligram/milliliter injection solution to treat intestinal lymphangiectasia, malabsorption due to intolerance, and diarrhea. 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, including the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnoses 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 diagnosis. Therefore, the requested drug is not eligible for coverage under Medicare Part D.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 Rivastigmine 4.6-milligram per 24-hour transdermal patch to treat mild cognitive impairment. 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, including the case file from the plan, and any information submitted at the reconsideration level.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. On the contrary, as outlined in the Medicare approved compendium, American Hospital Formulary Service Drug Information (AHFS-DI), Cholinesterase inhibitors including Rivastigmine have been investigated in patients with mild cognitive impairment; however, evidence of benefit is lacking. Results of a systematic review of 9 randomized, double-blind, placebo-controlled studies of cholinesterase inhibitors in patients with mild cognitive impairment showed no strong evidence of a beneficial effect on progression to dementia and essentially no effect of these drugs on cognitive test scores. An increased risk of adverse effects, particularly gastrointestinal effects, was observed with these drugs. These findings do not support the use of cholinesterase inhibitors in individuals presenting with memory complaints who do not meet diagnostic criteria for dementia. Therefore, the requested drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D.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 Phenazopyridine Hydrochloride 200-milligram tablets to treat overactive bladder symptoms. 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.Phenazopyridine Hydrochloride has not been found by the Food and Drug Administration (FDA) to be safe and effective, and the drug product labeling has not been approved by the FDA. Drugs not approved by the FDA do not meet the definition of a Part D drug and are excluded from Part D coverage. 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 Otezla 30-milligram tablets to treat moderate to severe plaque psoriasis. 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 documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The requested drug is not on the plans formulary. 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 documentation does not support why all alternative drugs provided on the plans formulary list would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm.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 Bystolic 5-milligram tablet to treat hypertension. The Part D plan denied the request. The requested drug is not on the plans formulary. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 asked your prescriber to send us a prescriber statement, answers to off-formulary exception coverage criteria, and medical records. However, we did not receive the documentation.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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Apixaban 5 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee requested the Part D plan to provide reimbursement for the requested drug purchased from a network pharmacy and processed through the enrollee's prior Part D plan in error. However, the current Part D plan indicates that there is missing information needed to consider the request. The documentation provided includes some of the missing elements with the exception of the prescribing physicians information. The required information should include the prescribing physicians name, address and National Provider Identifier (NPI) number. Therefore, we determined that the plan is not required to reimburse the enrollee without the required information. Please provide this information to the plan for reimbursement consideration.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nurtec 75-milligram oral disintegrating tablets to treat migraine unspecified, not intractable, without status migrainosus. 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, including the case file from the plan, and any information submitted at the reconsideration level.The requested drug is not on the plans formulary. 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 documentation does not support why alternative drugs provided on the plans formulary list would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm.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 Metoprolol Succinate 100-milligram extended release tablets to treat essential hypertension. 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.This drug is included on Tier 1 of the plans formulary. There are no cost-sharing tiers lower than Tier 1; therefore, a tier exception cannot be considered.  A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ondansetron 8-milligram oral dispersible tablets to treat nausea. 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.The provided diagnosis of nausea by itself is not a medically accepted indication for the use of Ondansetron outlined in the Medicare approved compendia. During this review, a request was submitted to the prescriber to clarify the diagnosis and to address the plans prior authorization requirements for coverage of this drug. However, the prescriber did not respond to the request. As such, the available documentation indicates that the requested drug is being prescribed for a non-medically accepted indication 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 Diclofenac Sodium 3-percent topical gel to treat cervical spine stenosis, cervical sprain/strain, and cervical radiculopathy. 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, including the case file from the plan, and any information submitted at the reconsideration level.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 requested drug is not eligible for coverage under Medicare Part D. 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 Lidocaine 5-percent patch. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted including 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 has satisfied the plans prior authorization coverage criteria. However, we did not receive the requested information.Thee was no documentation provided by the prescriber to support a covered diagnosis. We requested information from the prescriber but no information was received. We are not able to determine whether the requested drug was prescribed for a medically accepted indication. Therefore, the drug is not eligible for coverage under Medicare Part D.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 Advair Diskus 250-microgram/50-microgram inhalation powder to treat mild intermittent asthma. 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, including the case file from the plan, and any information submitted at the reconsideration level.Advair Diskus is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this drug is not eligible for a tiering exception.A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140-milligram/milliliter solution auto injector to treat hypercholesterolemia. 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, including the case file from the plan, and any information submitted at the reconsideration level.The requested drug is not on the plans formulary. 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 documentation does not support why alternative drugs provided on the plans formulary list would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm.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 Dupixent 300-milligram/2-milliliter solution pen injector to treat transient acantholytic dermatosis. 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, including the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis 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 diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D.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 Botox 100-unit solution for injection to treat secondary Raynaud's phenomenon due to the presence of progressive systemic sclerosis. 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, including the case file from the plan, and any information submitted at the reconsideration level.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 requested drug is not eligible for coverage under Medicare Part D.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 Myrbetriq 50-milligram extended release tablets to treat benign prostatic hyperplasia with urge 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 documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Myrbetriq is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this drug is not eligible for a tiering exception.A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Pushtronex System Solution Cartridge to treat hyperlipidemia. The Part D plan denied the request. The requested drug is not on the plans formulary. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 you.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 Dexilant 60-milligram delayed release capsules to treat gastroesophageal reflux 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 documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Dexilant is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this drug is not eligible for a tiering exception.A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Farxiga 5-milligram tablets to treat heart failure, to reduce risk of cardiovascular death or hospitalization. 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, including the case file from the plan, and any information submitted at the reconsideration level.The requested drug is not on the plans formulary. 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 documentation does not support why alternative drugs provided on the plans formulary list would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm.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 Itraconazole 10-milligram per milliliter oral solution prescribed for the prevention of aspergillosis fungal infection in an enrollee who is at high risk for infection due to immunosuppressive therapy after undergoing a lung transplant. 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, including the case file from the plan, and any information submitted at the reconsideration level.The requested drug is not on the plans formulary. 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 documentation does not support why the alternative drugs provided on the plans formulary list would likely not be as effective for this diagnosis, and/or would likely cause adverse reactions or other harm.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 Sildenafil Citrate 20-milligram tablet to treat erectile dysfunction. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted including the case file from the plan and any information submitted at the reconsideration level.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other diagnoses for which the drug is not Food and Drug Administration (FDA) approved are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.