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

At issue is a request for coverage of Aimovig 140 milligram per milliliter subcutaneous injection pen prescribed for migraines. The Part D plan denied the request for coverage. Additionally, the 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. The Part D plan has prior 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 have not been satisfied by the provided medical records. Since the plans requirements have not been satisfied and coverage for the drug is not supported, a tiering exception is not applicable to this review. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Cyanocobalamin (vitamin B-12) 1000 microgram per milliliter solution for injection prescribed for pernicious anemia. 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. Cyanocobalamin is a prescription vitamin. Prescription vitamins are excluded from coverage under Medicare Part D. It is possible that Medicare benefits may be used to provide access to vitamin B-12 shots through Medicare Part A or Part B under certain circumstances. If your Medicare-approved doctor determines that it is medically necessary to administer a vitamin B-12 shot, it may be covered by Part B. If you have been formally admitted into a hospital, reside in a skilled nursing facility, or hospice and your physician orders a vitamin B-12 shot as medically necessary treatment, Part A (hospital insurance) may help cover the costs.Medicare Part D prescription drug coverage can include a variety of drugs that are covered under individual plans; however, there are certain medical treatments that are expressly excluded by Part D, including vitamins, minerals and supplements. This means that vitamin B-12 is not covered under Part D as an injection or as an oral tablet. 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 Nurtec 75 milligrams oral disintegrating tablet. 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.Nurtec 75 milligrams oral disintegrating tablet is 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 your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Sodium/Gabapentin/Lidocaine HCL/Propylene Glycol/PCCA Custom Lipo-Max compound prescribed for osteoarthritis and tendinitis. The Part D plan denied your request We performed and 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. In this case, Diclofenac Sodium/Gabapentin/Lidocaine HCL/Propylene Glycol/PCCA Custom Lipo-Max compound is being used as a compounded bulk powder drug. Drugs compounded from bulk powders are not Food and Drug Administration approved; and therefore, are not covered under the Medicare Part D benefit. As such, the plan is not required to cover the compounded bulk power drugs at issue.In conclusion, the decision of the QIC is unfavorable.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested prior authorization for Humira (CF) Pen PS-UV-AHS 80-40 prescribed as directed for granuloma annulare. 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 information submitted at the reconsideration level. The documentation shows your doctor prescribed Humira (CF) Pen to treat your granuloma annulare. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Humira (CF) Pen.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Invokamet 150-500 milligram oral tablet. 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 information submitted at the reconsideration level. We asked your prescriber to send us information regarding 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 other medications on the plan's formulary would not work for you. However, we did not receive the documentation.There was no diagnosis given at initial determination. In addition, no medical records were submitted for review. Therefore, it cannot be determined if the requested drug was prescribed for a medically accepted indication supported by the Medicare approved compendia. The formulary exception was not addressed because the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Invokamet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Rybelsus 7 milligram tablets prescribed for Type 2 diabetes mellitus. The Part D plan denied your request. We performed 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.Rybelsus is a brand drug on Tier 2 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 a formulary exception request for Oxycodone Hydrochloride 15 milligram ER tablets prescribed for radiculopathy and chronic back pain. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. The submitted documentation did not include a supporting statement. A request for information was sent to your physician. Your physician submitted a supporting statement. The supporting statement did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Oxycodone Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Budesonide 0.5 milligram per 2 milliliter suspension. 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 indicates that Budesonide suspension has been prescribed for the treatment of post nasal drip, nasal congestion, and chronic rhinosinusitis. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted conditions. Therefore, the drug is being prescribed for non-medically accepted indications and is not eligible for coverage under Medicare Part D. It should be noted that Budesonide is available as a nasal spray; however, the Budesonide suspension being requested is meant to be used for inhalation therapy administered by a nebulizer. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Dronabinol 5 milligram capsules prescribed twice daily for anorexia, neoplasm related pain and other specified mononeuropathies. 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 information submitted at the reconsideration level. The documentation shows your doctor prescribed Dronabinol to treat your anorexia, neoplasm related pain and other specified mononeuropathies. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Wakix 4.45 milligram oral tablet prescribed daily for excessive daytime sleepiness with associated obstructive sleep apnea. 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 information submitted at the reconsideration level.The documentation shows your doctor prescribed Wakix to treat your excessive daytime sleepiness with associated obstructive sleep apnea. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Wakix.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Sodium 3 percent gel prescribed as directed for acute pain of right shoulder, neck pain, right elbow tendinitis, and acute foot pain. 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 information submitted at the reconsideration level. The documentation shows your doctor prescribed Diclofenac Sodium 3 percent gel to treat your acute pain of right shoulder, neck pain, right elbow tendinitis, and acute foot pain. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Diclofenac Sodium 3 percent gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nulojix for solution 250 milligram vials prescribed 500 milligram intravenous infusion every 28 days for a history of kidney 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.The record shows the enrollee received Nulojix following a Medicare covered kidney transplant on May 11, 2020. Therefore, the drug is eligible for coverage under Medicare Part B and excluded from Part D coverage.This decision does not concern 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

You requested Ethyl Alcohol 100% liquid prescribed as part of a compound drug to treat erectile dysfunction. 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 information submitted at the reconsideration levelThe record shows Ethyl Alcohol is an ingredient in a compounded drug that is reviewed individually. Medicare Part D does not cover drugs that do not meet the definition of a Part D drug. Therefore, we determined that the plan is not required to cover or reimburse for the Ethyl Alcohol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reauthorization of Repatha Sureclick 140 milligram/milliliter auto-injector prescribed for pure hypercholesterolemia. 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. Your plan has prior authorization requirements for continuation of this drug that must be met before they will cover the requested drug. The documentation provided does not support you have satisfied the plan's prior authorization requirements. Laboratory evidence provided does not demonstrate improvement while using this drug.A physician reviewed your appeal and determined that the plan is not required to cover Repatha Sureclick. 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 a request for coverage of Octreotide 100 microgram per milliliter solution for injection. 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 indicates that Octreotide has been prescribed for recurrent gastrointestinal bleeding secondary to arteriovenous malformations in the jejunum. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the 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 Bydureon B-Cise 2 milligram per 0.85 milliliter auto-injector to treat Type 2 diabetes mellitus with hyperglycemia. 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 also researched Medicare systems and reviewed the enrollment data available. Bydureon B-Cise 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 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 your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydroxyzine Hydrochloride 25-milligram tablet to treat pruritus. The case was auto-forwarded by the plan.  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 record shows your prescriber ordered Hydroxyzine Hydrochloride to treat your pruritus. A request was submitted to the prescriber to provide a diagnosis, to clarify the medical history, to address the prior authorization criteria, and to provide supporting medical records.  We received documentation and included it in our review.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 a formulary exception request for Vyvanse 30 milligram capsules prescribed for attention deficit hyperactivity disorder. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. The submitted documentation did not include a supporting statement. A request for information was sent to your physician. Your physician submitted a supporting statement. The supporting statement did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Vyvanse.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue a request for coverage of Tobramycin 300 milligram per 5 milliliter inhalation solution prescribed for the treatment of chronic lung disease with recurrent pneumonia. 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 documentation indicates that the Tobramycin inhalation solution is going to be administered via nebulizer. Medicare rules state that Medicare Part B pays for the rental and purchase of durable medical equipment, such as a nebulizers. Payment will also be made under Medicare Part B for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals, which must be put directly into the equipment to achieve the therapeutic benefit of the durable medical equipment. Coverage under Part D is excluded for any drug for which payment would be available under Part B. We determined that the Medicare Part D plan is not required to cover the requested drug. 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. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Invokana. 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. Invokana 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

You requested Tacrolimus 1 milligram capsule prescribed for aplastic anemia. 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 information submitted at the reconsideration level. The documentation shows your doctor prescribed Tacrolimus prescribed for aplastic anemia. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Tacrolimus.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 24-26 milligram tablet prescribed twice daily for dilated cardiomyopathy. 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.Entresto 24-26 milligram tablet 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 Rytary ER 23.75 milligram-90 milligram capsules prescribed for Parkinsons disease. 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 Rytary ER to treat your Parkinsons disease. 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.  On the Prior authorization request form dated 6/18/2021 and signed by the prescriber the prescriber stated that the enrollee has NOT had previous treatment or intolerance to Carbidopa-Levodopa IR or ER.  A physician reviewed your appeal and determined that the plan is not required to cover Rytary ER.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Taladafil 5 milligram tablet prescribed for erectile dysfunction. The Part D plan denied your 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 record shows that your doctor prescribed Tadalafil to treat sexual or erectile dysfunction. We determined that the plan is not required to cover the Tadalafil. Medicare excludes certain drugs from Part D coverage. Tadalafil is an excluded drug when used to treat sexual or erectile dysfunction; or to treat a condition other than sexual or erectile dysfunction for which the drug has not been approved by the Food and Drug Administration. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.