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

At issue is coverage for Oxycodone Hydrochloride ER (extended release) 20 milligram tablet to treat chronic pain. 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 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 and failed, or deemed contraindicated. In this case, the prescriber has not addressed the formulary alternative drug required by the plan to treat the enrollees condition, Xtampza ER, and provided patient specific clinical rationale with supporting medical records as to why the formulary alternative would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. It should be noted that the formulary alternative drug, Xtampza ER, is a branded version of the drug being requested, Oxycodone Hydrochloride ER. The documentation provided to the plan includes a prescriber statement dated August 1, 2022, that indicates the prescriber would not recommend the enrollee switching to Xtampza ER. However, no patient specific clinical/medical rationale has been given for this recommendation. A new prescriber statement dated August 9, 2022, has been submitted at reconsideration. In this prescriber statement, it is noted that the enrollee was required to switch to Xtampza and she hasnot tolerated the medication which has caused headaches, nausea and upset stomach. However, no medical records have been submitted to confirm the enrollee has tried and failed Xtampza ER anytime during the 8-day period from the first prescriber statement dated August 1, 2022, through the second prescriber statement dated August 9, 2022. Therefore, there is insufficient documentation to support a formulary exception in this case.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 non-formulary coverage request and a tiering exception request for Travatan Z 0.004 percent eye drops to treat bilateral primary open-angle glaucoma. The Part D plan denied both requests. 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 and failed, or deemed contraindicated. In this case, the prescriber has not addressed all of the formulary alternatives required by the plan to treat the enrollees condition and provided patient specific clinical rationale as to why each formulary alternative would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Therefore, the formulary exception criteria have not been met and Part D coverage for the drug in not eligible. Since the drug is not eligible for coverage, a tiering exception is not applicable.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 Advair Diskus 250 microgram/50 microgram inhalation to treat chronic obstructive pulmonary 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 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 the formulary alternatives, required by the plan 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 Pulmozyme 1 milligram per milliliter solution to treat persistent pulmonary secretions status post lung 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.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 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 coverage for Testosterone Cypionate 200 milligram per milliliter injection solution to treat male hypogonadism. The Part D plan denied the request for coverage due to a lack of information/response from the prescriber to determine if the plans prior authorization requirements were 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 plan has prior authorization requirements for this drug that must be met before coverage can be approved. While the prescriber has submitted a prescriber statement at reconsideration, not all of the plans coverage requirements have been addressed in this statement. Additionally, the submitted documentation does not include any medical records, including the actual testosterone laboratory results from the laboratory showing the standard lab reference values, to confirm that all of the plans requirements for coverage have been met.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Fentanyl 100 microgram per hour transdermal 72-hour patch to treat chronic pain. 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.Fentanyl 100 microgram per hour transdermal 72-hour patch is a generic drug on Tier 4 of the plans formulary. The prescriber has not provided patient specific clinical rationale as to why the drugs of the same type on the lower tiers of the plans formulary to treat the enrollees condition have been tried and failed, or are contraindicated. A physician reviewer determined that the tiering exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Creon DR 36000 unit/114000 unit/180000 unit capsule to treat pancreatic steatorrhea. 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.Creon DR is a biologic on Tier 3 of the plans formulary. There are no biologics of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this biologic 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 a tiering exception request for Eliquis 5 milligram tablets as anti-coagulation therapy for the prophylaxis of deep vein thromboses. 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 submitted documentation supports the drug at issue was prescribed for the prophylaxis of deep venous thromboses. The Medicare approved compendia contain citations to support the use of the drug for this condition. Therefore, the drug at issue was prescribed for a medically accepted indication.However, Eliquis 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 diagnosis. 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 Chlorzoxazone 500 milligram tablets to treat acute muscle spasms due to a chronic condition. 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 Temazepam 15 milligram capsules (90 capsules per 90 days) to treat the enrollees diagnosis of insomnia. 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 limits the amount of Temazepam provided as a 30-day supply. Therefore, an exception to the plans coverage criteria is not supported. 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 coverage for Pimecrolimus 1 percent cream to treat other specified dermatitis; poikiloderma of civatte; and allergic dermatitis, unspecified cause. 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 reviewed all documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.The noted conditions are off-label uses for the requested drug. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these conditions. Therefore, the drug is being prescribed for non-medically accepted indications.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Buprenorphine 10 microgram per hour weekly transdermal patch to treat chronic back pain. 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.Buprenorphine 10 microgram per hour weekly transdermal patch is a generic drug on Tier 4 of the plans formulary. The prescriber has not addressed all drugs on the lower tiers of the plans formulary to treat the noted condition and provided patient specific clinical rationale as to why each lower-tiered drug would be less effective as the requested drug, is contraindicated, and/or or has been tried and failed.A physician reviewer determined that tiering exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Sildenafil Citrate 20 milligram tablet to treat pulmonary hypertension due to left heart disease. 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 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 noted condition 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 condition. Therefore, the drug is being prescribed for a non-medically accepted indication.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 Tremfya 100 milligram per milliliter injector to treat plaque psoriasis. 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 the formulary alternatives, required by the plan 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 Eliquis 5 milligram tablets as anti-coagulation therapy for the prophylaxis of cerebral vascular accident and systemic embolism in an enrollee with 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.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 the formulary alternatives, required by the plan 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 a tiering exception request for Livalo 4 milligram tablets to treat the enrollee's condition. 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.Livalo 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 diagnosis. 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 Pregabalin 50 milligram capsules to treat post herpetic neuralgia. 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: Favorable

At issue is Promacta 50 milligram tablets to treat idiopathic thrombocytopenic purpura. 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 satisfies the plans coverage criteria. The submitted documentation supports the enrollee has a diagnosis of idiopathic thrombocytopenic purpura. The Medicare approved compendia contain citations to support the use of the drug for this condition. Therefore, the drug was prescribed for a medically accepted indication. Furthermore, the prescriber has submitted laboratory results to show the enrollee has a platelet count of less than 50000 per microliter.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 coverage for Mycophenolate Mofetil 500 milligram tablet to treat necrotizing myositis related to 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-COA) reductase antibodies. 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 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 noted condition 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 condition. Therefore, the drug is being prescribed for a non-medically accepted indication.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 Lynparza 100 milligram tablets to treat advanced ovarian cancer, BRCA1 mutated, as maintenance therapy in combination with Avastin. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Contrave 8-90 milligram extended release 12 hour tablet to treat obesity. 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.Drugs prescribed to treat weight gain (promote weight loss) 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 Hyoscyamine Sulfate 0.125 milligram sublingual tablets. The Part D plan denied the request as an excluded drug in the Medicare Part D program.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.For the drug at issue to be covered under Medicare Part D, the manufacturer must participate in the Medicare Coverage Gap Discount Program. This manufacturer is not participating in the program; therefore, the drug is excluded from Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliquis 5 milligram tablets as anti-coagulation therapy for the prophylaxis of cerebral vascular accident and systemic embolism in an enrollee with 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.Eliquis 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 diagnosis. 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: Favorable

At issue is coverage for Piqray 150 milligram tablet (300 milligram daily dose) dose pack to treat metastatic breast cancer (HR positive, HER2 negative) with PIK3CA mutation in a postmenopausal enrollee. The Part D plan denied the request for coverage because the use of the requested drug in combination with the drug, Femara, to treat the provided diagnosis was not a medically accepted indication for the drug. 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.At reconsideration, the prescriber has clarified that the Femara will be discontinued and that the enrollee will be prescribed Faslodex to be used in combination with the requested drug, Piqray, to treat the enrollees metastatic breast cancer (HR positive, HER2 negative) with PIK3CA mutation. The use of the requested drug to be used in combination with Faslodex to treat the noted condition is a medically accepted indication for the drug outlined in the Food and Drug Administration (FDA) product label and the Medicare approved compendia. The plans only prior authorization requirement for the drug is that it is being prescribed for an FDA-approved indication or a medically accepted off-label indication. As such, the documentation submitted at reconsideration confirms that the plans prior authorization requirement for the drug has been satisfied, as the drug is being prescribed for an FDA-approved indication.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.