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

At issue is Corlanor 5-milligram tablets to treat chronic heart failure with ischemic cardiomyopathy. The Part D plan denied the request for coverage because the plans prior authorization requirements were not met. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The documentation satisfies the plans coverage criteria. The drug is being requested to treat chronic heart failure, which is a medically accepted indication outlined in the Medicare approved compendia. The documentation supports the enrollee has tried and failed/ was intolerant of beta-blocker medications, Metoprolol and Bisoprolol. Additionally, the echocardiogram report obtained on September 28, 2021, which has been submitted at reconsideration, shows that the enrollees ejection fraction is 30 to 35 percent. Therefore, the newly submitted report validates the enrollees ejection fraction is less than or equal to 35 percent, and all of the plans coverage requirements have been met. The plan does not have step therapy or quantity limit requirements for this drug. As such, 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 Tacrolimus 0.1 percent ointment to treat dermatitis, unspecified. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Engerix-B (hepatitis B vaccine) 20-microgram per milliliter prefilled syringe. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. The documentation indicates that the requested drug is being given because the enrollee is at high or intermediate risk of contracting hepatitis B, as the enrollee has diabetes mellitus and decompensated cirrhosis. When an enrollee is at high or intermediate risk of contracting Hepatitis B, coverage for the hepatitis B vaccine is available under Medicare Part B. Drugs that are eligible for Part B coverage are excluded from Part D coverage by Medicare law. 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 Posaconazole 100-milligram delayed release tablet for fungal infection prophylaxis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D.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 Saxenda 3-milligram per 0.5-milliliter subcutaneous injection pen. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Although the prescriber has noted the requested drug is being used to treat type 2 diabetes, the only Food and Drug Administration (FDA)-approved indication for the brand drug, Saxenda, is for the management of obesity. As outlined in the Medicare approved compendium, American Hospital Formulary Service Drug Information (AHFS-DI), the Saxenda preparation of Liraglutide is not intended for use in the treatment of type 2 diabetes mellitus. Drugs prescribed to treat weight gain/promote weight loss (even if used for a non-cosmetic purpose, i.e., morbid obesity) are excluded from the Part D coverage. Therefore, since obesity management is the only approved indication for the requested drug, it is excluded from coverage Part D coverage. 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 Eliquis 5-milligram tablets to treat atrial flutter/fibrillation. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The requested drug is not on the plans formulary. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the documentation does not support why alternative drugs provided on the plans formulary list would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm.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 Lorazepam 2 milligram/milliliter vial to treat laryngeal spasms. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Xeljanx 5-milligram tablet to treat to treat rheumatoid arthritis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including 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 prescriber statement to support the enrollee has satisfied the plans prior authorization coverage criteria. We received additional documentation and included it in the review,The documentation shows the enrollee had an intolerance to Methotrexate. The documentation satisfies the plans coverage criteria. 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 Pregablin 50-milligram capsules to treat pain in left knee. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 4 percent patch to treat sciatica associated with disorder of the lumbar spine. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Lidocaine 4 percent patch is available over the counter. Drugs prescribed that are available over the counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Xarelto 10-milligram tablets prescribed as anticoagulation therapy for an enrollee with paroxysmal atrial fibrillation. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Xarelto 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 noted condition. Therefore, this drug is not eligible for a tiering exception.A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vraylar 3-milligram capsules to treat anxiety and depression. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eysuvis 0.25-percent ophthalmic suspension to treat allergic conjunctivitis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Veltassa 8.4-gram powder packet to treat hyperkalemia. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including 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 prescriber statement to support all formulary alternatives were tried and failed or were contraindicated. However, we did not receive the requested information.The requested drug is not on the plans formulary. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the documentation does not support why alternative drugs provided on the plans formulary list would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Radicava 30-milligram per 100-milliliter intravenous solution, delivered IV in the home by gravity feed to treat amyotrophic lateral sclerosis. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted.We requested additional information from the prescriber. Specifically, we requested documentation to support all formulary alternatives were tried and failed or were contraindicated. We received additional documentation and included it in the review.The use of the requested drug to treat amyotrophic lateral sclerosis is a medically accepted indication as outlined in the Medicare approved compendia. However, the drug is not on the plans formulary. The only drug on the plans formulary indicated for the treatment of amyotrophic lateral sclerosis is Riluzole. The prescriber has noted and the submitted medical records that validate the enrollee is currently taking both Riluzole and Radicava for the treatment of amyotrophic lateral sclerosis. The prescriber notes that this is a continuation of therapy and the Radicava continues to slow disease progression, allowing enrollee to maintain function. The prescriber recommends continued treatment with both Riluzole and Radicava. Since the formulary alternative is already being taken by the enrollee, an exception to the plans formulary coverage criteria is supported.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 Onpattro 10-milligram/5-milliliter vial, 10-milliliter every three weeks to treat neuropathic heredofamilial amyloidosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted including the case file from the plan and any information submitted at the reconsideration level.The record shows Onpattro is to be administered to the enrollee intravenously through an external infusion pump used in the home. According to Medicare rules, Medicare Part B pays for the rental and purchase of durable medical equipment, if the equipment is used in the patients home. Payment may be made under 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. We determined that the Medicare Part D plan is not required to cover Onpattro. 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 Xeljanz 5-milligram tablet. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including 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 prescriber statement to support the diagnosis that requires treatment with the requested drug and that the enrollee has satisfied the plans prior authorization coverage criteria. However, we did not receive the requested information. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Retacrit 20000-units/milliliter to treat anemia in chronic kidney disease. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The requested biologic is not on the plans formulary. In order to grant an exception for a biologic not on the plans formulary, alternative formulary biologics must have been tried, failed, or deemed contraindicated. In this case, the documentation does not support why alternative biologics provided on the plans formulary list would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm.A physician reviewed the appeal and determined that the requested biologic is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humira Citrate-free 40-milligrams per 0.4-milliliter pen injection kit to treat Rasmussen syndrome with intractable seizures. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Benztropine Mesylate 2-milligram tablets to treat extrapyramidal disease - medication-induced movement disorder. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria.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 Mycophenolate Mofetil 250 milligram capsule prescribed for an enrollee who is status post a kidney transplant. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including 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. We determined that the plan is not required to cover the drug. Medicare records indicate the enrollee received a kidney transplant, which was covered by Medicare Part A. Therefore, the transplant is considered a Medicare covered transplant and the requested drug is eligible under Medicare Part B. Medicare rules state that a drug covered under Part B cannot be covered under Part D. 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 Tacrolimus 1-milligram capsule prescribed twice daily for an enrollee who is status post a kidney transplant. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including 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. We determined that the plan is not required to cover the drug. Medicare records indicate the enrollee received a kidney transplant, which was covered by Medicare Part A. Therefore, the transplant is considered a Medicare covered transplant and the requested drug is eligible under Medicare Part B. Medicare rules state that a drug covered under Part B cannot be covered under Part D. 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 Ubrelvy 50-milligram tablets to treat episodic tension-type headache. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The prescriber indicated on appeal the enrollee has a diagnosis of chronic migraine without aura. However, the medical records submitted do not support a change in diagnosis. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550-milligram tablets to treat irritable bowel syndrome with diarrhea. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria.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 Inqovi 35-milligram/100-milligram tablets to treat chronic myelomonocytic leukemia in combination with Idhifa. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. Medicare-approved compendia do not contain any citations to support the use of the requested drug as prescribed, for treatment of the noted diagnosis. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.