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

You asked the Plan to cover Diclofenac 1% Gel. The Plan did not grant this request. We received this caseto conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Diclofenac 1% Gel.Diclofenac 1% Gel is requested for treatment of shoulder pain and radiculopathy, which are off-label (non-FDA approved) uses. The Medicare-approved compendia do not contain any citations to support the use ofthe requested drug, as prescribed, for treatment of the noted conditions. Therefore, the requested drug is notbeing prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptionsrequest based on medical necessity cannot be considered because the requested drug, as prescribed, doesnot meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverageunder Medicare Part D for the noted conditions.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically acceptedindication. A medically accepted indication means a use that is approved by the FDA or a use that issupported by one or more citations in Medicare approved compendia.Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicareapproved compendia that support the use of Diclofenac 1% Gel for the diagnosed conditions. As a result,the drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, itcannot be covered under the Medicare Part D benefit for these conditions. An exceptions request based onmedical necessity cannot be considered because this drug, as prescribed, does not meet the definition of aMedicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage forDiclofenac 1% Gel.This decision does not concern the medical necessity of the requested drug. It only establishes if paymentcan be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Armodafinil. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Armodafinil.The drug is requested to treat narcolepsy. The prescriber has not indicated why one of the formulary alternatives required by the Plan (Dextroamphetamine ER, Metadate or Methylphenidate ER, or Modafinil) would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is not supported.Our Physician Reviewer's opinion is that formulary exception criteria are not met.A Plan must grant an exception for a drug that is not on its formulary if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on a review of the available documentation, our Physician Reviewer's opinion is that formulary exception criteria are not met. Therefore, the Plan is not required to cover Armodafinil.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Nubeqa 300 mg tablet. The Plan did not grant this request. We received thiscase to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Nubeqa 300 mg. The drug is requested to treat non-metastatic castration resistant prostate cancer.The enrollee is a 76 year old man with prostate cancer that has been treated with radiation and Eligard. Hehas a rising PSA from 1.25 in May 2019, to 1.71 in November 2019, to 2.1 in May 2020. Axumin PET/CTimaging was negative for distant metastases on June 10, 2020. You request Nubeqa to be given withongoing Eligard to treat him.Per the FDA website, Nubeqa is indicated for the treatment of patients with non-metastatic castrationresistant prostate cancer (nmCRPC). The enrollee has non-metastatic prostate cancer as indicated by therecent negative imaging. He is castration resistant as indicated by the rising PSA on Eligard, which is aform of androgen deprivation. He will continue on Eligard. Therefore he meets the prior authorizationcriteria.For coverage under the prescription drug benefit, Medicare requires that the drug prescribed be used for amedically accepted indication. Our Physician Reviewer found that the Medicare-approved resources docontain citations to support the use of the requested drug for treatment of the noted condition. Therefore,the requested drug is being prescribed for a medically accepted indication. The enrollee satisfies the Plan'scoverage criteria. Our Physician Reviewer's opinion is that prior authorization criteria are met.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically acceptedindication. A medically accepted indication means a use that is approved by the FDA or a use that issupported by one or more citations in Medicare approved compendia. Our Physician Reviewer reviewedthis file and determined that there are citations in the Medicare approved compendia that support the use ofNubeqa 300 mg tablet for the diagnosed condition. As a result, Nubeqa 300 mg tablet is being prescribedfor a medically accepted indication as defined by Medicare law.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs.Based on the available documentation, our Physician Reviewer's opinion is that prior approval criteria aremet. Therefore, our decision is the Plan is required to cover Nubeqa 300 mg tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Dronabinol, 2.5 mg. The Plan did not grant this request. We received this caseto conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Dronabinol, 2.5 mg.The drug is requested for the treatment of weight loss. Additional medical information was requested by thePart D QIC, however, the prescribing physician statement was not returned. Drugs prescribed for thetreatment of weight loss are excluded from coverage. Therefore, this drug is excluded from coverage.Medicare law excludes certain drugs from Part D coverage. Dronabinol, 2.5 mg is one of those excludeddrugs because it is a drug used for anorexia, weight loss or weight gain. The record submitted by the Plandoes not indicate that they provide supplemental coverage for Dronabinol, 2.5 mg. Therefore, the Plan isnot required to cover Dronabinol, 2.5 mg.This decision does not address the medical necessity or appropriateness of the requested drug. It onlyestablishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover NP Thyroid. The Plan did not grant this request. We received this case toconduct an independent review. Medicare Part D does not cover drugs that are not FDA approved for both safety and effectiveness. Wedetermined that NP Thyroid is not FDA approved for both safety and effectiveness by checking FDAsources. Therefore, the Plan is not required to cover NP Thyroid.This decision does not address the medical necessity or appropriateness of the requested drug. It onlyestablishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Farxiga. The Plan did not grant this request. Wereceived this case to conduct an independent review.Medicare rules do not require the Part D plan to grant a tiering exception for a brand or biologic drug of thesame type if the lower tier(s) on the formulary only contain(s) generic alternative drugs. Farxiga is a Tier 3brand drug. The lower cost-sharing tier(s) only contain(s) generic alternative drugs. Therefore, our decisionis the Plan is not required to provide a tiering exception for Farxiga.
Appeal type: Prescription Drug
Decision: Partially Favorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for Aspirin 81 mg, Acetaminophen 325 mg, Docusate Sodium 100 mg, Amlodipine 5 mg, Celecoxib 200 mg, Metoprolol Succinate 50 mg, Oxycodone HCL ER 10 mg, Scopolamine 1.5 mg, Tramadol 50 mg and Furosemide 20 mg received October 7, 2019 and October 8, 2019. The Plan did not grant this request. We received this case to conduct an independent review.Aspirin, Acetaminophen and Docusate SodiumMedicare Part D does not cover non-prescription drugs. We checked FDA approved sources for the drugs' classifications or determined from other available resources that the drugs are a non-prescription or OTC drug. Therefore, Aspirin, Acetaminophen and Docusate Sodium received October 7, 2019 and October 8, 2019 not eligible for Part D coverage, and the Plan is not required to cover or provide reimbursement for them under the Part D benefit.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.Amlodipine, Celecoxib, Metoprolol Succinate, Oxycodone HCL ER, Scopolamine, Tramadol and FurosemideThe Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. In this case, you were a patient at the hospital in October 2019. You received several self-administered drugs during this stay. You requested reimbursement from the Part D Plan. The Plan did not process the request. Amlodipine, Celecoxib, Metoprolol Succinate, Oxycodone HCL ER, Scopolamine, Tramadol and Furosemide are Part D eligible drugs. Additionally, a representative from Maximus Federal verified with the hospital that the self-administered drug portion of the bill has been paid in full. The Plan's out-of-network coverage rules were followed. Therefore, our decision is the Plan is required to provide coverage and reimbursement for Amlodipine 5 mg, Celecoxib 200 mg, Metoprolol Succinate 50 mg, Oxycodone HCL ER 10 mg, Scopolamine 1.5 mg, Tramadol 50 mg and Furosemide 20 mg received October 7, 2019 and October 8, 2019.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Prolia 60 mg/mL as prescribed. The Plan did not grant this request. Wereceived this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Prolia 60 mg/mL injection.The drug is requested to treat osteoporosis. On 6/26/2020 the prescriber sent additional information andmedical records addressing the Plan's coverage criteria including documentation that the enrollee is not onany other osteoporosis medication other than calcium and vitamin D. The enrollee satisfies the Plan'scoverage criteria.Our Physician Reviewer's opinion is that prior authorization criteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs.Based on the available documentation, our Physician Reviewer's opinion is that prior approval criteria aremet. Therefore, our decision is the Plan is required to cover Prolia.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Symbicort. The Plan did not grant this request. Wereceived this case to conduct an independent review.Medicare law and Plan rules do not allow tiering exceptions for non-formulary drugs being coveredthrough a formulary exception. The documentation in the record shows that Symbicort is currently beingcovered for the enrollee through a formulary exception. Therefore, our decision is the Plan is not requiredto provide a tiering exception for Symbicort.
Appeal type: Prescription Drug
Decision: Favorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Revlimid, 25 mg capsule as prescribed. The Plan did not grant this request. Wereceived this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Revlimid, 25 mg capsule.The drug is requested to treat multiple myeloma. A request for prescriber statement and medical recordswas sent. The statement and medical records were returned. The enrollee satisfies the Plan's coveragecriteria. Our Physician Reviewer's opinion is that prior authorization criteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs.Based on the available documentation, our Physician Reviewer's opinion is that prior approval criteria aremet. Therefore, our decision is the Plan is required to cover Revlimid, 25 mg capsule as prescribed.
Appeal type: Prescription Drug
Decision: Favorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Austedo 12 mg tablet. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Austedo 12 mg tablet. The drug is requested to treat G24.01 Drug induced subacute dyskinesia. You were asked to address the Plan's prior authorization criteria and to provide supporting medical records. On June 29, 2020 you addressed the coverage criteria and provided recent (dated June 13, 2020) supporting office notes. The enrollee satisfies the Plan's coverage criteria. Our Physician Reviewer's opinion is that prior authorization criteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. Based on the available documentation, our Physician Reviewer's opinion is that prior approval criteria are met. Therefore, our decision is the Plan is required to cover Austedo 12 mg tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Repatha Sureclick. The Plan did not grant this request. We received this caseto conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Repatha Sureclick 140 mg/ml. The drug is requested to treat Heterozygous FamilialHypercholesterolemia. The enrollee does not satisfy the Plan's coverage criteria. The prescriber has notsufficiently addressed the Plan's coverage criteria and/or has not indicated why all alternatives required bythe Plan would likely not be as effective for the enrollee as the requested drug, and/or would likely causeadverse reaction(s) or other harm to the enrollee. Our Physician's opinion is that neither prior authorizationnor prior authorization exception criteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. APlan must grant an exception to prior approval rules if it determines that the requested drug is medicallynecessary, consistent with the prescriber's statement. Based on the available documentation, our PhysicianReviewer's opinion is that an exception to prior approval criteria is not met. Therefore, the Plan is notrequired to cover Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Lidocaine 5% Patch. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Lidocaine 5% patch. The drug was initially requested to treat pain due to a closed fracture in a patient with rectal malignancy, and subsequently requested to treat pain due to a left femur fracture and other specified post-procedural states. You were asked to clarify the enrollee's diagnoses, because it was unclear from the case file. You were also asked to address prior authorization coverage criteria. A response from you was not received. Therefore, based on the current record, there is insufficient documentation that the requested medication is being prescribed for a medically accepted indication as defined by Medicare law. In addition, prior authorization exception criteria are not met.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. A medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia. Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicareapproved compendia that support the use of Lidocaine 5% Patch for the diagnosed conditions. As a result, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be covered under the Medicare Part D benefit for these conditions. An exceptions request based on medical necessity cannot be considered because this drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage for Lidocaine 5% Patch. This decision does not concern the medical necessity of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Yupelri nebulizer solution. The Plan did not grant this request. We receivedthis case to conduct an independent review.Medicare law specifically excludes coverage for any drug for which payment would be available under PartA or Part B of Medicare for that individual. Medicare Part B may pay for supplies necessary for theeffective use of durable medical equipment, including drugs and biologicals which must be put directly intothe equipment in order to achieve the therapeutic benefit of the durable medical equipment. Medicare PartB local policy states that a small volume nebulizer and related compressor are covered when medicallynecessary to administer Yupelri for the management of obstructive pulmonary disease.We requested additional medical information to determine if criteria for Medicare Part D have been met.We requested the enrollee's diagnosis and ICD-10 code for which Yupelri has been prescribed, andconfirmation of where this drug is being administered. A response to our request was not received in thetimeframe required for review of this case. There is insufficient information to show that this drug is noteligible for Medicare Part B coverage. As a result, the record does not establish that Yupelri is a Part Ddrug in this case. Therefore, it is our decision that the Part D Plan is not required to cover Yupelri.This decision does not concern the medical necessity or appropriateness of the requested drug. It onlyestablishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Shingrix Vaccine. The Plan did not grant this request. We received this case toconduct an independent review.Shingrix (DOS September 24, 2019)In this case, the enrollee requested reimbursement for Shingrix Vaccine purchased September 24, 2019from the pharmacy. The record shows that the Plan provided coverage for Shingrix Vaccine. When theclaim for Shingrix Vaccine was processed, the enrollee was in the coverage gap. While in the coverage gap,the enrollee is required to pay 25% for brand name drugs or 36% for generic drugs. The amount theenrollee was charged was less than or equal to the required coverage gap copayment. The cost of ShingrixVaccine was applied to the enrollee's yearly true out-of-pocket (TrOOP) costs. Therefore, our decision isthe Plan is not required to provide reimbursement for Shingrix Vaccine.Shingrix (DOS January 21, 2020)You asked the Plan to provide reimbursement for Shingrix purchased on January 21, 2020 from thepharmacy. The Plan did not grant this request. We received this case to conduct an independent review.Medicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. If an enrolleepays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof ofpayment to ask the Plan to pay its share of the cost. The Plan required a $37 copyament for up to a 30 daysupply of a Tier 3 drug purchased from a preferred retail pharmacy in 2020. A request for reimbursementwas submitted to the Plan. In this case, the Plan provided documentation showing that this claim wascovered by the Plan at the time of purchase. The record shows that Shingrix was purchased for an amountthat is less than or equal to the required copayment amount.The case record indicates that the Plan provided coverage in accordance with the Part D contract.Therefore, our decision is the Plan is not required to provide reimbursement for Shingrix purchased onJanuary 21, 2020 from the pharmacy.