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

You asked the Plan to cover Stelara. The Plan did not grant this request. We received this case to conductan independent review.Medicare law specifically excludes coverage for any drug for which payment would be available underParts A or B of Medicare for that individual. Medicare Part B pays for services and supplies incident to theservice of a physician (or other practitioner).In this case, the record reflects that Stelara will be supplied from physician and/or office stock supply, andwill be billed as part of a physician service. Stelara is a type of drug that is not usually self-administered.As a result, the drug as administered in this case appears to be eligible for coverage under Medicare Part B.Drugs which are eligible for coverage under Part B are excluded from Part D coverage by Medicare law.Therefore, it is our decision that the Part D Plan is not required to cover Stelara.This decision does not concern the medical necessity or appropriateness of the requested drug. It onlyestablishes if payment can be made under the Medicare Part D benefit.You may wish to submit this request to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Lyrica. The Plan did not grant this request. We received this case to conductan independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Lyrica 100 mg cap. The drug is requested to treat neuralgia & neuritis multiple sclerosis, which is anoff-label (non-FDA approved) use. The Medicare-approved compendia do not contain any citations tosupport the use of the requested drug, as prescribed, for treatment of the noted condition. Therefore, therequested drug is not being prescribed for a medically accepted indication as defined by Medicare law. Assuch, an exceptions request based on medical necessity cannot be considered because the requested drug, asprescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is noteligible for coverage under Medicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically acceptedindication. A medically accepted indication means a use that is approved by the FDA or a use that issupported by one or more citations in Medicare approved compendia.Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicareapproved compendia that support the use of Lyrica for the diagnosed condition. As a result, the drug is notbeing prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot becovered under the Medicare Part D benefit for this condition. An exceptions request based on medicalnecessity cannot be considered because this drug, as prescribed, does not meet the definition of a MedicarePart D drug. Therefore, our decision is that the Plan is not required to provide coverage for Lyrica.This decision does not concern the medical necessity of the requested drug. It only establishes if paymentcan be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Rituxan. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Rituxan. The drug is requested to treat transverse myelitis, which is an off-label (non-FDA approved) use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. A medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia. Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicare approved compendia that support the use of Rituxan for the diagnosed condition. As a result, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be covered under the Medicare Part D benefit for this condition. An exceptions request based on medical necessity cannot be considered because this drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage for Rituxan. This decision does not concern the medical necessity of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Diclofenac Epolamine. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Diclofenac Epolamine 1.3% Patch. The drug is requested to treat chronic pain syndrome/radiculopathy/bilateral knee osteoarthritis pain/shoulder pain, which are off-label (non-FDA approved) uses. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted conditions. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted conditions.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. A medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia. Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicare approved compendia that support the use of Diclofenac Epolamine for the diagnosed condition. As a result, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be covered under the Medicare Part D benefit for this condition. An exceptions request based on medical necessity cannot be considered because this drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage for Diclofenac Epolamine. This decision does not concern the medical necessity of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Mycophenolate Mofetil. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Mycophenolate Mofetil 500 mg. The drug is requested to treat anterior scleritis, right eye, which is an off-label (non-FDA approved) use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. A medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia. Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicare approved compendia that support the use of Mycophenolate Mofetil for the diagnosed condition. As a result, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be covered under the Medicare Part D benefit for this condition. An exceptions request based on medical necessity cannot be considered because this drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage for Mycophenolate Mofetil. This decision does not concern the medical necessity of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Cidofovir 2%, Hydrolatum, and Mineral Oil. The Plan did not grant thisrequest. We received this case to conduct an independent review.Cidofovir 2%Medicare Part D does not cover drugs that are not FDA approved for both safety and effectiveness. Wedetermined that Cidofovir 2% is not FDA approved for both safety and effectiveness by checking FDAsources. Therefore, the Plan is not required to cover Cidofovir 2%.This decision does not address the medical necessity or appropriateness of the requested drug. It onlyestablishes that payment cannot be made under the Medicare Part D benefit.Hydrolatum and Mineral OilMedicare Part D does not cover non-prescription drugs. We checked FDA approved sources for the drug'sclassification or determined from other available resources that the drug is a non-prescription or OTC drug.Therefore, Hydrolatum and Mineral Oil are not eligible for Part D coverage, and the Plan is not required tocover it under the Part D benefit.This decision does not address the medical necessity or appropriateness of the requested drug. It onlyestablishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Nuedexta. The Plan did not grant this request. We received this case toconduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Nuedexta 20-10 mg capsule. Nuedexta 20-10 mg capsule is requested to treat pseudobulbar affect withAlzheimer's dementia. For coverage under the prescription drug benefit, Medicare requires that the drugprescribed be used for a medically accepted indication. Our Physician Reviewer found that the Medicareapprovedresources do contain citations to support the use of the requested drug for treatment of the notedcondition. Therefore, the requested drug is being prescribed for a medically accepted indication. Theenrollee does not satisfy the Plan's coverage criteria. The prescriber has not sufficiently addressed the Plan'scoverage criteria and/or has not indicated why all alternatives required by the Plan would likely not be aseffective for the enrollee as the requested drug, and/or would likely cause adverse reaction(s) or other harmto the enrollee. Of note, a request for records was sent to the prescriber as the diagnosis for the requesteddrug was changed at the reconsideration level from Alzheimer's disease with behavioral disturbance topseudobulbar affect. Despite the request, no supporting medical records to substantiate the prescriber'sindicated diagnosis were provided. Our Physician's opinion is that neither prior authorization nor priorauthorization exception criteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. APlan must grant an exception to prior approval rules if it determines that the requested drug is medicallynecessary, consistent with the prescriber's statement. Based on the available documentation, our PhysicianReviewer's opinion is that an exception to prior approval criteria is not met. Therefore, the Plan is notrequired to cover Nuedexta.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide reimbursement for Citalopram 20 mg, Trazodone HCL 50 mg, Montelukast10 mg, Levothyroxine 100 mcg and Bupropion HCL ER SA 150 mg purchased on January 13, 2020 from astandard retail pharmacy. The Plan did not grant this request. We received this case to conduct anindependent review.Medicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. If an enrolleepays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof ofpayment to ask the Plan to pay its share of the cost. The Plan required a $24.00 copayment for Tier 1 drugsand a $45.00 copayment for Tier 2 drugs for up to a 90 day supply purchased from a standard retail in2020. A request for reimbursement was submitted to the Plan. In this case, the Plan provideddocumentation showing that this claim was covered by the Plan at the time of purchase. The record showsthat Citalopram 20 mg, Trazodone HCL 50 mg, Montelukast 10 mg, Levothyroxine 100 mcg andBupropion HCL ER SA 150 mg were purchased for an amount that is less than or equal to the requiredcopayment amount.The case record indicates that the Plan provided coverage in accordance with the Part D contract.Therefore, our decision is the Plan is not required to provide reimbursement for Citalopram 20 mg,Trazodone HCL 50 mg, Montelukast 10 mg, Levothyroxine 100 mcg and Bupropion HCL ER SA 150 mgpurchased on January 13, 2020 from a standard retail pharmacy.Your complaint regarding being told by the Plan to have your prescriptions filled at CVS Pharmacy is agrievance. A grievance is any complaint or dispute, other than one that involves a coverage determinationor at-risk determination, expressing dissatisfaction with any aspect of the operations, activities, or behaviorof a Part D plan. Grievance procedures are separate and distinct from appeal procedures. Medicare definesa coverage determination as (1) a decision not to provide or pay for a Part D drug, (2) failure to provide acoverage determination in a timely manner, when a delay would adversely affect the health of the enrollee,(3) a decision concerning an exceptions request, or (4) a decision on the amount of cost-sharing for a drug.(42 CFR ??423.560, 423.564(b), 423.566(b)).Since your complaint involves a grievance, the Part D Plan must review this complaint under the Plan'sgrievance procedures. Each Part D Plan must provide meaningful procedures for timely hearing andresolving grievances between enrollees and the Part D Plan (or any other entity or individual through whomthe Part D Plan provides covered benefits under any Part D Plan it offers). At this time, you should contactthe Plan for information on how to proceed with having this complaint reviewed under the Plan's grievanceprocedures. 42 CFR Section 423.564(a).
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Velcade. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Velcade injection powder for solution 3.5 mg. The drug is requested to treat kidney transplant status/rejection prophylaxis, which is an off-label (non-FDA approved) use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. A medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia. Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicare approved compendia that support the use of Velcade for the diagnosed condition. As a result, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be covered under the Medicare Part D benefit for this condition. An exceptions request based on medical necessity cannot be considered because this drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage for Velcade. This decision does not concern the medical necessity of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Astagraf XL ER. The Plan did not grant this request. We received this case to conduct an independent review.Medicare law specifically excludes coverage for any drug under the Part D program for which payment would be available under Parts A or B of Medicare for that individual. Coverage is available under Medicare Part B for prescription drugs used in immunosuppressive therapy furnished to a beneficiary who has received an organ transplant, provided that Medicare Part A paid for the transplant in question. The case record indicates that Astagraf XL ER is needed for a kidney transplant performed August 10, 2016. According to the case record, the transplant in question was paid for by Medicare Part A. Thus, the transplant is considered a Medicare covered transplant and Astagraf XL ER is eligible for coverage under Medicare Part B. Drugs which are eligible for Part B coverage are excluded from Part D coverage by Medicare law. Therefore, our decision is that Part D Plan is not required to cover Astagraf XL ER. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.You may wish to submit this request to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Nulojix. The Plan did not grant this request. We received this case to conductan independent review.Medicare Part B local policy states that immunosuppressive drugs are covered only for the specific labeledindications and approval for marketing by the FDA. The Medicare Part B rules state that parenteral Belatacept(Nulojix) is not proven to be safe when administered in the home setting, and therefore will be denied underMedicare Part B as not medically necessary when provided in that setting. The case record indicates thatNulojix will be administered in the home. Nulojix would therefore not be eligible for coverage under MedicarePart B in this case. Thus, Nulojix may be eligible for coverage under Medicare Part D. We therefore asked ourPhysician Reviewer to determine if Part D coverage criteria have been met, including addressing safetyconcerns.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Nulojix 250 mg/ vial IV solution. The drug is requested for prophylaxis of organ rejection in thisEpstein-Barr virus (EBV) seropositive kidney transplant recipient (12/12/2014). The requested drug issubject to B versus D prior authorization criteria. The requested drug is not eligible for coverage under PartB rules, as the requested intravenous (IV) infusion will be administered in the enrollee's home. You havedocumented that the enrollee is s/p BK viremia, s/p pancytopenia, EBV seropositive, received Basiliximabfor induction, and concomitant Mycophenolate Mofetil and corticosteroids. You stated that Tacrolimus andSirolimus have been tried for the prevention of renal transplant rejection. Our Physician Reviewer's opinionis that prior authorization criteria are met. The enrollee satisfies the Plan's coverage criteria.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs.Based on the available documentation, our Physician Reviewer's opinion is that prior approval criteria aremet. Therefore, our decision is the Plan is required to cover Nulojix.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Lyrica 100 mg capsule. The Plan did not grant this request. We received thiscase to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Lyrica 100 mg capsule. The drug is requested to treat neuropathy. Lyrica 100 mg capsule is not on thePlan's formulary. Lyrica CR tablets are on the Plan's formulary. You have not indicated why all alternativesrequired by the Plan would likely not be as effective for the enrollee as the requested drug; and/or wouldlikely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan'scoverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exception criteria arenot met.A Plan must grant an exception for a drug that is not on its formulary if it determines that the requesteddrug is medically necessary, consistent with the prescriber's statement. Based on a review of the availabledocumentation, our Physician Reviewer's opinion is that formulary exception criteria are not met.Therefore, the Plan is not required to cover Lyrica 100 mg capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Keflex. The Plan did not grant this request. We received this case to conductan independent review.CMS publishes a list of participating brand name drug manufacturers that have signed the MedicareCoverage Gap discount agreement. Keflex is a brand name drug, and its manufacturer is not on this list.Therefore, the Part D Plan is not required to cover Keflex.