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

At issue is Dronabinol 2.5 milligram capsules prescribed as an appetite stimulant. 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 determined that the plan is not required to cover Dronabinol because it was prescribed for weight gain. Drugs to treat anorexia, weight loss, or weight gain are excluded from coverage. 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 Anoro Ellipta 62.5-25 micrograms inhaler prescribed to treat chronic obstructive pulmonary disease. The Part D plan denied the 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.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 Anoro Ellipta 62.5-25 micrograms inhaler.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ursodiol 500-milligram tablet. At initial determination and redetermination the diagnoses of calculus of gallbladder and bile duct without cholecystitis without obstruction and unspecified cirrhosis of liver were given. The Part D plan denied the request. 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.At reconsideration a diagnosis of primary biliary cholangitis was given. No medical records were provided by the prescriber to support this diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. 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 Victoza 18 milligram/3 milliliter pen injector 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.Victoza is a brand drug on Tier 3 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 Lotemax 0.5% gel eye drops prescribed for severe dry eye syndrome and chronic Meibomian gland dysfunction. 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 Lotemax 0.5% gel eye drops for severe dry eye syndrome and chronic Meibomian gland dysfunction. 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 Lumakras 120 milligram tablets prescribed for the treatment of metastatic stage IV pancreatic cancer with KRAS mutation. The Part D plan denied the request. 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. The submitted documentation does not include any peer-reviewed, clinically relevant, medical literature from an approved journal to support this appeal. Therefore, the requested drug is being prescribed for a non-medically accepted indication as defined by Medicare. As such, an exceptions request based on medical necessity cannot be considered because the requested drug does not meet the definition of a Medicare Part D drug. A physician reviewed the appeal and determined that the plan is not required to cover Lumakras.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Tymlos 3120 microgram per 1.56 milliliter subcutaneous injection pen, 1 pen (1.56 milliliters) per 30 days, prescribed for postmenopausal osteoporosis. 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. During this review, a prescriber statement and supporting medical records were requested from the prescriber. The prescriber responded and submitted the requested documentation.The submitted medical records indicate that Tymlos had been prescribed for the treatment of postmenopausal osteoporosis with a high risk of fracture, which is a medically accepted indication for Tymlos as outlined in the Medicare approved compendia. The Part D plans requirements for coverage of Tymlos include that the enrollee has a high risk for fractures. The submitted medical records support that the enrollee has a high risk for fractures as evidenced by a history of previous fractures, including a fracture of the arm in 2016, fractures of calcaneus and sacrum in June 2020, and most recently, a wedge-compression fracture of the T11 to T12 thoracic vertebrae. It is also noted that the enrollees latest dual-energy X-ray absorptiometry (DEXA) scan obtained in April of 2019 confirms the enrollee has low bone mass density with a total hip T-score of -2.4 and a femoral neck T-score of -3.1. An additional requirement by the plan is that the enrollee has had an adequate trial of, intolerance to, or a contraindication to one bisphosphonate. As noted in the medical records the enrollee has tried both Fosamax and Boniva without success. Another requirement included in the plan is that the enrollee is unable to use/tolerate oral therapy. However, this requirement is not applicable to the enrollee as oral therapy has been tried and failed with two separate osteoporosis drugs. The plans final requirement for coverage of the requested drug is that the enrollee has not received a total of 24 months cumulative treatment with any parathyroid hormone therapy. The prescriber has noted that the enrollee has not received a total of 24 months cumulative treatment with any parathyroid hormone therapy. Therefore, the submitted documentation supports that the plans prior authorization requirements have been satisfied. The plans quantity limit for the drug is 1.56 milliliters per 30 days, which is what has been ordered by the prescriber.  To summarize, the documentation supports that the medication is being used for a medically accepted indication, the plans prior authorization requirements have been met, and the quantity limit has not been exceeded. Therefore, coverage for the drug can be allowed. A physician reviewed the appeal and determined that the plan is required to cover Tymlos.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Quinine Sulfate 324 milligram capsules 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 Quinine Sulfate 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. For informational purposes only, the  prior authorization questionnaire was returned indicating use for nocturnal leg cramps. The Medicare approved compendia, Micromedex, issues a negative citation for this use, with the warning of potential serious side effects.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 Shingrix 50 microgram/0.5 milliliter injection prescribed for a vaccination. 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.Shingrix is a brand 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 Sildenafil 20 milligram tablets prescribed for pulmonary hypertension, World Health Organization group 3. 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 Sildenafil for pulmonary hypertension, World Health Organization group 3. 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 Memantine HCL 5 milligram tablet prescribed for autistic disorder and disruptive mood dysregulation disorder. 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.The documentation shows the doctor prescribed Memantine HCL to treat the enrollees autistic disorder and disruptive mood dysregulation disorder. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition(s). A physician reviewed your appeal and determined that the plan is not required to cover Memantine HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ondansetron 4-milligram tablet to treat nausea, unspecified. 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 support the use of this drug for your 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 Calcipotriene 0.005% cream prescribed for Grovers disease. 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 Calcipotriene cream for Grovers disease. 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

The enrollee requested Np Thryroid 120 milligram tablet prescribed for unknown diagnosis. 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. According to Medicare rules, drugs that are not approved by the Food and Drug Administration are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover the Np Thyroid tablet. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine-Prilocaine 2.5%-2.5% cream. 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 related to the enrollees end-stage renal disease. 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 Ajovy 225 milligrams per 1.5 milliliters auto-injector to treat an unknown condition.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 QIC asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication is needed. We did not receive the requested documentation.The appeal is for Ajovy 225 milligrams per 1.5 milliliters auto-injector. However, there were no medical records submitted supporting the enrollees condition. The QIC is unable to determine if the enrollees condition is a medically-accepted indication to support the use of the requested drug.A physician reviewed the appeal and determined that the plan is not required to cover Ajovy 225 milligrams per 1.5 milliliters auto-injector.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq ER 25 milligram tablet to treat overactive bladder. 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 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. Myrbetriq ER  is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers to treat the same condition. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your 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 Horizant ER 600 milligram extended release tablets prescribed for restless leg syndrome. 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. Horizant 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. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Ongentys 50 milligram capsules prescribed for Parkinsons 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 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. Ongentys 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. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for Budesonide ER 9 milligram tablet prescribed 90 tablets every 30 days for unknown diagnosis. 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. A request was submitted to the prescriber to provide a diagnosis and to provide supporting medical records.  A reply from the prescriber was not received.  Without a diagnosis, it cannot be established that the requested drug is being prescribed for a medically accepted indication.  As such, the requested drug does not satisfy the definition of a Medicare Part D drug.  Therefore, 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. The request for a tiering exception was not reviewed. We cannot consider a tiering exception for a drug for which the Medicare Part D plan is unable to provide coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Dermotic 0.01% oil. 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 does not include medical records or a prescriber supporting statement. A request for information was sent to the prescriber; however, no further documentation was received. 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 Humira Pen Psoriasis/Uveitis Starter Pack to treat plaque psoriasis. 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 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

At issue is Metformin Hydrochloride ER 24 hour 500 milligram tablet prescribed daily for type 2 diabetes. 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 records submitted at the reconsideration level.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication was needed. We did not receive the documentation requested.The doctor prescribed Metformin Hydrochloride ER to treat the enrollees type 2 diabetes. The 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 the appeal and determined that the plan is not required to cover Metformin Hydrochloride ER. 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 Cimzia 200 milligram/milliliter solution prescribed for rheumatoid arthritis. 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 biologic not on the plans formulary, alternative formulary biologics must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other biologics on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Cimzia.