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

At issue is Ibrance 125-milligram capsules prescribed for laryngeal cancer. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation indicates the prescriber ordered the drug at issue for the enrollees noted condition. The use of the drug for the enrollees condition is an off-label use. The prescriber submitted a Medicare-approved peer-reviewed journal article to support the use of the drug for the noted condition. The article supports the use of Ibrance for head and neck cancers in enrollees that are platinum-resistant, Cetuximab-resistant, and are HPV unrelated. The prescriber submitted a statement to support the enrollee meets all the criteria of the study. An exception to the plans prior authorization criteria can be allowed. A physician reviewed your appeal and determined that the plan is required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lumakras 120 milligram tablets prescribed for metastatic rectosigmoid cancer. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates the prescriber ordered the drug at issue for the enrollees noted condition. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. There were no Medicare-approved peer-reviewed journal articles submitted to support the use of the drug for the noted 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 formulary exception request for Gamunex-C 10-grams/100 milliliter solution prescribed for chronic inflammatory demyelinating polyneuropathy. 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 did not indicate that all the formulary alternatives were tried and failed and/or would be ineffective.A physician reviewed the appeal and determined that the plan is not required to cover Gamunex-C.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Odomzo 200 milligram capsules, one capsule to be taken daily, which has been prescribed for the treatment of locally advanced basal cell carcinomas of the face associated with Gorlin syndrome. The Part D plan denied the request stating that there was confirmation the disease progressed while the enrollee was taking the drug vismodegib (Erivedge).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.As outlined in the Medicare approved compendia, the use of Odomzo for the treatment of basal cell carcinoma of the skin is a medically accepted indication for the drug. The plans first prior authorization requirement for the drug if it is being used to treat locally advanced basal cell carcinoma is that the basal cell carcinoma has recurred following surgery/radiation therapy or the enrollee is not a candidate for surgery/radiation therapy. As noted in the submitted medical records, the enrollee has had several facial surgeries in past for resection of basal cell carcinomas with recurrence. The plans other prior authorization requirement is that the enrollee must not have had disease progression while taking the drug, Erivedge. The prescriber has clarified at reconsideration that the enrollee had to stop taking Erivedge due to constipation and elevated liver function tests; however, the enrollee did not have disease progression while taking the Erivedge. The submitted medical records substantiate that the enrollee had to stop taking Erivedge due to intolerance of the drug; not due to disease progression.Therefore, the documentation submitted at reconsideration supports that the plans requirements for coverage of Odomzo to treat locally advanced basal cell carcinoma have been met. The plans quantity limit requirements for the drug is 30 capsules per 30 days, which is what has been prescribed. Therefore, coverage for the drug can be allowed. A physician reviewed the appeal and determined that the plan is required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Botox 200 units pen injector for the enrollees condition. The Part D plan allowed the requested drug under a formulary exception, but denied the appeal 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.The biological drug, Botox 200 units pen injector, has been provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Amitiza 24 microgram capsules prescribed for opioid-induced constipation. The Part D plan denied coverage.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The submitted documentation does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.  The prescriber was asked to submit medical records.  There were no medical records submitted to support the enrollee has tried and failed, or has a contraindication to, Movantik and Relistor.  Also note that on the Prior Authorization request form submitted to the plan and dated 8/12/2021 the prescriber stated that the enrollee did not try, fail or have a contraindication to Movantik and Relistor.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 Ursodiol 300 milligram tablets prescribed as directed. The Part D plan denied your 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. We asked your prescriber to send us information about your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why similar medications on the lower tiers would not work for you. . However, we did not receive the documentation.Ursodiol is a generic drug on Tier 4 of the plans formulary. Your doctor did not address why the drugs available on the lower tiers of your plans formulary would not work for you. 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 your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch prescribed for dorsalgia. The Part D plan denied the request.We received a 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 record shows the enrollee received the drug at issue on April 7, 2021, April 15, 2021, and April 16, 2021. The documentation submitted does not include a receipt or proof of payment for the requested drug. Therefore, coverage cannot be allowed.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Lynparza 150 milligram tablets prescribed for the treatment of metastatic castration-resistant prostate cancer with HRR gene mutation. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The plan has authorization requirements that must be met before coverage of this medication will be approved. The submitted medical records do not support that the plans coverage criteria have been satisfied. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Verapamil Hydrochloride 360-milligram extended release capsules prescribed for atrial flutter. The Part D plan denied the request for a tiering exception.vWe 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.We requested additional documentation from the prescriber. Specifically, we requested a prescriber statement to support why lower-tier alternatives would not work for the enrollee. We received additional information and included in in the review.Verapamil Hydrochloride is a generic drug on Tier 3 of the plans formulary. The prescriber submitted a supporting statement. The supporting statement did not address why all the drugs available on the lower tiers of the plans formulary would not work. 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 Panzyga 10% intravenous solution prescribed for immunosuppression following a lung-liver transplant. 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.On appeal, the submitted documentation indicates the prescriber ordered the drug at issue for immune deficiency following a lung-liver transplant.   On the Prior Authorization request form dated 9/2/2021 the prescriber was asked to list the indication for the enrollee's immune deficiency and the prescriber wrote, 'Lung-Liver Transplant.'  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 biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligram/milliliter solution auto injector prescribed as directed for primary hyperlipidemia. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Repatha Sureclick to treat your primary hyperlipidemia. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for  Ubrelvy 100 milligram tablets prescribed to treat the enrollees condition.   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.This drug is being provided by the plan at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Epolamine 1.3% 12-hour transdermal patch prescribed to treat the enrollee with lumbar stenosis, cervical spondylosis, and thoracic radiculopathy. The Part D plan denied the appeal 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 Diclofenac Epolamine 1.3% 12-hour transdermal patch to treat lumbar stenosis, cervical spondylosis, and thoracic radiculopathy. However, the Medicare approved compendia do not support the use of this drug for the enrollees conditions.A physician reviewed your appeal and determined that the plan is not required to cover Diclofenac Epolamine 1.3% 12-hour transdermal patch.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Cinacalcet Hydrochloride 30 milligram tablets. The Part D plan denied the request because coverage for the drug would be available under Medicare Part B, as the records showed that the enrollee was receiving dialysis. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The prescriber statement and medical records submitted at reconsideration indicate that the enrollee underwent a kidney transplant on February 6, 2020, and is no longer receiving dialysis. Therefore, coverage of the drug would not be available under Medicare Part B. The medical records also indicate that Cinacalcet Hydrochloride has been prescribed for the treatment of hypercalcemia in a renal transplant recipient with persistent hyperparathyroidism. This is a medically accepted indication for the drug as outlined in the Medicare approved compendia. Therefore, the records submitted at reconsideration confirm that the drug is not available for coverage under Medicare Part B, as the enrollee is no longer receiving dialysis, and that the drug is being used for a medically accepted indication. The plans quantity limit for the drug is 120 tablets per 30 days. The prescriber has requested 30 tablets per 30 days. Therefore, coverage for the drug can be allowed. 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 a request for coverage of Prolastin-C 1000 milligram per 20 milliliter intravenous solution prescribed for the treatment of alpha-1-antitrypsin deficiency with underlying emphysema. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The plan has authorization requirements that must be met before coverage of this medication will be approved. 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 a tiering exception request for Restasis 0.05% eye emulsion prescribed for the treatment of keratopathy symptoms. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Restasis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no brand 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 plan is not required to cover the requested drug at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tacrolimus 0.5-milligram capsules prescribed twice daily following a liver transplant. 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 also researched Medicare systems and reviewed the enrollment data available. Based on the information provided, the drug is eligible for Part B 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 Humalog mix 75-25 units per milliliter subcutaneous suspension prescribed to administer 70 units in the morning and 70 units in the evening to treat type II diabetes. The Part D plan denied the appeal 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.Documentation to support why the enrollee needs the requested drug at a daily dose exceeding the plans quality limits was not provided. Several unsuccessful attempts were made to contact the prescriber for the required documentation.The appeal request is for Humalog mix 75-25 units per milliliter subcutaneous suspension to treat type II diabetes. The plans quantity limit for the requested drug is 100 units per day with 3 vials in 30 days. The prescriber orders 140 units per day with 4 vials in 30 days. The Part D plan denied the request stating that the quality limitation requirements were not met. No documentation has been provided to support why an exception to the plans quantity limit is medically necessary.A physician reviewed the appeal and determined that the plan is not required to cover Humalog mix 75-25 units per milliliter subcutaneous suspension for 140 units per day with 4 vials in 30 days, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ozempic 1 milligram/dose prescribed as directed. The Part D plan denied your 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. Ozempic 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 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 Lidocaine 5% patches prescribed for low back pain and bilateral ankle burning pain. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We requested additional information from the prescriber. Specifically, we requested medical records and a supporting statement. We received the requested information and included it in the review.The submitted documentation indicates the prescriber ordered the drug at issue for the enrollees noted condition. 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 Dronabinol 2.5 milligram capsule prescribed for nausea and vomiting associated with cancer. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. The information provided indicates Dronabinol 2.5 milligram capsule is prescribed to treat nausea and vomiting due to chemotherapy. The documents indicate it will not be used as a full therapeutic replacement for an intravenous antiemetic administration within 48 hours of chemotherapy and the enrollee will not require more than 24 hours of oral antiemetic therapy of Dolasetron or Granisetron. Therefore, the drug is Part D eligible. However, the plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. We requested additional information from the prescriber but did not receive a response. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Dronabinol. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.