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

At issue is Ultracare insulin pen needles 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.Ultracare insulin pen needles are on Tier 3 of the plans formulary. There are no other insulin needles on the lower cost sharing tiers. Therefore, the insulin pen needles 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 request for coverage of Prevymis 480 milligram tablets. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation indicates that Prevymis has been prescribed for the treatment of recurrent cytomegalovirus viremia and retinitis status post chemotherapy treatment for lymphoma. 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: Favorable

At issue is a request for coverage of Nucynta 100 milligram immediate release tablets. The Part D plan denied the request for coverage stating that the drug was being prescribed for a non-medically accepted indication. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The progress notes submitted at reconsideration show that Nucynta 100 milligram immediate release tablets have been prescribed, as needed, for the treatment of acute pain. The prescriber states in the progress notes that the enrollee is to take Nucynta immediate release tablets three to four times a day as needed for pain. It is noted that the enrollee is also taking Nucynta 150 milligram extended release tablets every 12 hours for chronic pain. The use of Nucynta immediate release tablets as needed for the treatment of acute pain is a medically accepted indication outlined in the Medicare approved compendia.Nucynta 100 milligram immediate release tablets are not included on the plans formulary. However, as noted by the plan, the enrollee has tried and failed two formulary alternative drugs and the formulary exception criteria have been met.Therefore, the drug is being prescribed for a medically accepted indication and a formulary exception is supported.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Sucraid 8500 unit per milliliter oral solution. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation indicates that Sucraid has been prescribed for the treatment of sucrase-isomaltase deficiency, not specified as congenital. However, as outlined in the Medicare approved compendia, the only medically accepted indication for the use of Sucraid is for the genetic sucrase deficiency that is part of congenital sucrase-isomaltase deficiency (CSID). 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 Trimo-San 0.025/0.01% gel prescribed for pessary insertion. 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 not Food and Drug Administration approved. 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 Cyanocobalamin 1000 micrograms per milliliter solution for injection to treat vitamin B-12 deficiency.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.According to Medicare rules, drugs that fall into the category of vitamins and minerals are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover the Cyanocobalamin. 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 Ritalin 10 milligram tablet requested for hypersomnia associated with 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 Ritalin was prescribed to treat hypersomnia associated with 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 Ritalin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Odactra 12 standardized quality (SQ) house dust mite (HDM) sublingual tablets. The Part D plan denied the request for coverage. 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 Odactra 12 SQ-HDM sublingual tablets have been prescribed for the treatment of moderate asthma and perennial allergic rhinitis due to house dust mites. As outlined in the Medicare approved compendium, DrugDex, Odactra sublingual immunotherapy is not approved for the use on enrollees over the age of 65-years-old. The enrollee is over 65-years-old. 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 Repatha Sureclick 140 milligram/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.Repatha Sureclick is a 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 a formulary exception request for Xeljanz 5 milligram tablets prescribed for severe, treatment-resistant dermatitis. 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 Xeljanz for severe, treatment-resistant dermatitis. 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

You requested Imvexxy starter pack vaginal insert prescribed for dyspareunia due to postmenopausal atrophic vaginitis. 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. We determined that the plan is not required to Imvexxy because it  was used to treat sexual dysfunction. Drugs prescribed for the treatment of sexual dysfunction 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 a formulary exception request for Sunosi 75 milligram tablets prescribed for unspecified hypersomnia. 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 documentation from the prescriber. Specifically, we requested medical records and a supporting statement to support formulary alternatives were tried and failed. However, we did not receive the requested information.The submitted documentation indicates the prescriber ordered Sunosi for unspecified hypersomnia. 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 Clonidine Hydrochloride 0.1 milligram extended release tablets. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation indicates that Clonidine Hydrochloride extended release tablets have been prescribed for the treatment of hypertension. However, the Medicare approved compendia do not contain any citations to support the use of Clonidine Hydrochloride extended release tablets for the treatment of hypertension. 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 Sivextro 200 milligram tablets prescribed for right ear chronic invasive otitis media with otomastoiditis due to multi-drug resistant mycobacterium abscessus. 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 Sivextro for right ear chronic invasive otitis media with otomastoiditis due to multi-drug resistant mycobacterium abscessus. 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 Corlanor 5 milligram tablet prescribed for autonomic dysfunction and postural orthostatic tachycardia syndrome. 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. The documentation shows Corlanor was prescribed to treat autonomic dysfunction and postural orthostatic tachycardia syndrome. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. This decision does not speak to the medical necessity of this drug for your condition. This decision speaks to whether your plan is required to provide coverage under Medicare rules. A physician reviewed your appeal and determined that the plan is not required to cover Corlanor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Cresemba 186 milligram capsules. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation indicates that Cresemba has been prescribed for antifungal prophylaxis in an immunocompromised enrollee. 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 a request for coverage of Vraylar 1.5 milligram capsules. The Part D plan denied the request for coverage because the medication was being used for a non-medically accepted indication. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The initial documentation provided to the plan indicates that Vraylar has been prescribed for the management of severe treatment-resistant depression with chronic suicidal ideation. 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. At reconsideration, the prescriber has included an additional diagnosis of bipolar depression. However, no medical records have been submitted to sustantiate this new diagnosis. Therefore, there is insufficient documentation to determine if the requested drug is being prescribed for a medically accepted indication. As such, the requested drug is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Victoza 0.6 milligram/0.1 milliliter injection prescribed for type II diabetes mellitus. The Part D plan denied the requestWe 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 requested additional documentation from the prescriber. Specifically, we requested medical records and a supporting statement to support the plans step therapy critera were met. However, we did not receive the requested information.The documentation shows the doctor prescribed Victoza for diabetes mellitus. The plan has step therapy 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 Victoza.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Albuterol Sulfate 2.5 milligram per 3 milliliter (0.083%) nebulizer solution. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation indicates that Albuterol Sulfate has been prescribed for the treatment of cough and wheeze in an enrollee with recurrent pneumonia due to chronic aspiration. 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 Aprepitant 80 milligram capsules prescribed for chemotherapy-induced nausea and vomiting. 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 will be used within two hours of chemotherapy as a full replacement for intravenous anti-emetic therapy. 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 Symbicort 160-4.5 microgram inhaler 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.Symbicort 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 a request for coverage of Vumerity 231 milligram delayed release capsules prescribed for the treatment of multiple sclerosis. 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. Vumerity 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 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. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage and a tiering exception request for Corlanor 7.5 milligram tablets. The Part D plan denied coverage for the medication and the tiering exception request because the medication was being prescribed for a non-medically accepted indication. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that Corlanor has been prescribed for the treatment of supraventricular tachycardia. 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. Since the drug is not eligible for coverage, a tiering exception is not applicable to this review. 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 Cresemba 186 milligram capsule prescribed as prophylaxis of invasive fungal infection in a patient with cryptogenic organizing pneumonia and neutropenia. 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. The documentation shows Cresemba was prescribed as prophylaxis of invasive fungal infection in a patient with cryptogenic organizing pneumonia and neutropenia. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Cresemba.