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

You asked the Plan to cover Austedo 6 mg. 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 Austedo 6 mg tablet. The drug is requested to treat Tardive Dyskinesia. The prescriber sent a statementdated 2/28/2020 clarifying the diagnosis and medical history. Medical records were provided to support thediagnosis. For coverage under the prescription drug benefit, Medicare requires that the drug prescribed beused for a medically accepted indication. Our Physician Reviewer found that the Medicare-approvedresources do contain citations to support the use of the requested drug for treatment of the noted condition.Therefore, the requested drug is being prescribed for a medically accepted indication.The enrollee has involuntary athetoid or choreiform movements, has a history of treatment with dopaminereceptor blocking agent and has moderate to severe tardive dyskinesia demonstrated by a score of 3 on item8 (severity of abnormal movements overall) on the Abnormal Involuntary Movement Scale (AIMS). Theenrollee's AIMS evaluation was provided from date of service 2/20/2020. The enrollee satisfies the Plan'scoverage criteria. Our Physician Reviewer's opinion is that prior authorization criteria are met.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 reviewedthis file and determined that there are citations in the Medicare approved compendia that support the use ofAustedo 6 mg for the diagnosed condition. As a result, Austedo 6 mg is being prescribed for a medicallyaccepted indication as defined by Medicare law.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 Austedo 6 mg.
Appeal type: Prescription Drug
Decision: Partially Favorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to to provide reimbursement for Tamsulosin 0.4 mg, Insulin Human Regular, Apixaban5 mg, Amiodarone T 200 mg, Potassium Chloride ER 20 meq, Nifedipine CC 60 mg, Citalopram 20 mg,Carvedilol 25 mg, Atorvastatin 40 mg, Isosorbide Mononitrate 60 mg, Insulin Glargine 10 U/mL, Novolog(Insulin Aspart) 10 mL, Percocet (Oxycodone-Acetaminophen), Potassium Chloride 10 meq, Losartan 100mg, Melatonin 5 mg, Aspirin T 81 mg, Benzocaine/Menthol Throat Lozenge and Magnesium Oxide 400mg received April 4, 2019 through April 6, 2019 and December 27, 2018 and December 28, 2018. The Plandid not grant this request. We received this case to conduct an independent review.Favorable DecisionThe Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances.In this case, you had two stays at the medical center in 2018 and 2019. You received several selfadministereddrugs during these stays. The request includes an itemized statement for both the December27, 2018 and December 28, 2018 and April 4, 2019 through April 6, 2019 stays. Proof of payment has beenestablished. The Plan's out-of-network coverage rules were followed. Therefore, our decision is the Plan isrequired to process and provide reimbursement for Tamsulosin 0.4 mg, Insulin Human Regular, Apixaban5 mg, Amiodarone T 200 mg, Potassium Chloride ER 20 meq, Nifedipine CC 60 mg, Citalopram 20 mg,Carvedilol 25 mg, Atorvastatin 40 mg, Isosorbide Mononitrate 60 mg and Insulin Glargine 10 U/mLreceived April 4, 2019 through April 6, 2019 while at AU Medical Center and Novolog (Insulin Aspart) 10mL, Percocet (Oxycodone-Acetaminophen), Potassium Chloride 10 meq, Nifedipine CC 60 mg,Citalopram 40 mg, Losartan 100 mg, Carvedilol 12.5 mg, Atorvastatin 40 mg, Isosorbide Mononitrate 60mg, and Insulin Glarine 10 U/mL received December 27, 2018 and December 28, 2018.Unfavorable DecisionMedicare Part D does not cover non-prescription drugs. We checked FDA approved sources for Aspirin T,Melatonin, Benzocaine/Menthol Throat Lozenge and Magnesium Oxide's classifications or determinedfrom other available resources that the drugs are a non-prescription or OTC drugs. Therefore, Melatonin 5mg and Aspirin T 81 mg received April 4, 2019 through April 6, 2019 while at AU Medical Center; andBenzocaine/Menthol Throat Lozenge, Aspirin T 81 mg and Magnesium Oxide 400 mg received December27, 2018 and December 28, 2018 are not eligible for Part D coverage, and the Plan is not required to coveror provide reimbursement for them 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 Repatha SureClick 140 mg/mL. The Plan did not grant this request. Wereceived this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Repatha SureClick 140 mg/mL.The drug is requested to treat the enrollee's condition. A request for prescriber statement was sent andreturned. The prescriber has not indicated why the Plan's formulary alternative Praluent is not appropriatefor the enrollee. The prescriber has not indicated why all alternatives required by the Plan would likely notbe as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or otherharm to the enrollee. Therefore, an exception to the Plan's coverage criteria is not supported. Our PhysicianReviewer's opinion is that formulary exception criteria are not 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 Repatha SureClick 140 mg/mL.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Restasis 0.05% Droperette. 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 Restasis 0.05% Droperette.The drug is requested to treat keratoconjunctivitis sicca and evaporative dry eyes, concurrently using punctal plugs. The enrollee does not satisfy the Plan's coverage criteria - concurrently using punctal plugs. The prescriber has not sufficiently addressed the Plan's coverage criteria and/or has not indicated why all alternatives required by the Plan would likely not be as effective for the enrollee as the requested drug, and/or would likely cause adverse reaction(s) or other harm to the enrollee. Our Physician's opinion is that neither prior authorization nor prior authorization exception criteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. A Plan must grant an exception to prior approval rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on the available documentation, our Physician Reviewer's opinion is that an exception to prior approval criteria is not met. Therefore, the Plan is not required to cover Restasis 0.05% Droperette.
Appeal type: Prescription Drug
Decision: Favorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Tetrabenazine, 12.5 mg tablet as prescribed. The Plan did not grant thisrequest. 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 requestfor Tetrabenazine, 12.5 mg tablet.Tetrabenazine, 12.5 mg is requested for ongoing treatment of Huntington's chorea. It is noted that theenrollee has been stable on the requested drug since October 12, 2018, and that any changes may result inadverse effects. The prescriber has indicated that the enrollee has a major depressive disorder, which isinadequately/insufficiently treated; however the prescriber has also indicated that the enrollee resides in along term care facility, and that the enrollee has been stable on the requested drug. The enrollee does notsatisfy the Plan's coverage criteria.The prescriber has indicated why all alternatives required by the Plan would likely not be as effective as therequested drug for the enrollee, and/or would likely cause adverse reaction(s) or other harm to the enrollee.Therefore, an exception to the Plan's coverage criteria is medically necessary. Our Physician Reviewer'sopinion is that prior authorization 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 met. Therefore, our decision is the Planis required to cover Tetrabenazine, 12.5 mg tablet as prescribed.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Inbrija 42 mg inhalation capsule. The Plan did not grant this request. Wereceived this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Inbrija 42 mg inhalation capsule.The drug is requested to treat Parkinson's disease. The prescriber has 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 Inbrija 42 mg inhalation capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Trintellix. The Plan did not grant this request. Wereceived this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor a tiering exception for Trintellix. The drug is requested to treat the enrollee's condition. The drug is abrand drug on tier 4 of the Plan's formulary. There are no available lower tier drugs on the Plan's formularyto treat the enrollee's condition. Therefore, the drug is not eligible for a tiering exception. Our PhysicianReviewer's opinion is that tiering exception criteria are not met.Medicare rules permit a Plan to grant an exception to its tiering structure so long as there is a drug of thesame type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) in alower cost-sharing tier approved for treating the same condition that the higher cost-sharing tiered drug isbeing used to treat. Our Physician Reviewer's opinion is that tiering exception criteria are not met becausethere are no lower cost-sharing tiered drugs of the same type for treating the enrollee's condition.Therefore, our decision is the Plan is not required to provide a tiering exception for Trintellix.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Tadalafil 5 mg. The Plan did not grant this request. We received this case to conduct an independent review. Medicare law excludes certain drugs from Part D coverage. Tadalafil 5 mg is one of those excluded drugs because it is a drug used to treat sexual or erectile dysfunction. The record submitted by the Plan does not indicate that they provide supplemental coverage for Tadalafil 5 mg. Therefore, the Plan is not required to cover Tadalafil 5 mg. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Oxycontin ER. 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 Oxycontin ER. The drug is requested to treat unspecified osteoarthritis/lumbago with sciaticaunspecified. You have not indicated why all alternatives required by the Plan (Xtampza ER) would likelynot be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) orother harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is not supported. OurPhysician Reviewer's opinion is that formulary exception criteria are not 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 Oxycontin ER.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Ofev. The Plan did not grant this request. We received this case to conduct anindependent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Ofev. The drug is requested to treat idiopathic nonspecific interstitial pneumonia, which is an off-label(non-FDA approved) use. Medical records from date of service 12/2/2019 were provided. Medical recordsdocument a bronchoscopy with a transbronchial lung biopsy. The biopsy report was as follows: Histologicsections from the specimen labeled transbronchial biopsies right lower lobe demonstrate mild interstitialfibrosis with histiocytes that show cytoplasmic vacuolation. This can be seen with Amiodarone use.The Medicare-approved compendia do not contain any citations to support the use of the requested drug, asprescribed, for treatment of the noted condition. Therefore, the requested drug is not being prescribed for amedically accepted indication as defined by Medicare law. As such, an exceptions request based onmedical necessity cannot be considered because the requested drug, as prescribed, does not meet thedefinition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage underMedicare 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 Ofev 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 Ofev.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 Hypersal 3.5% solution. The Plan did not grant this request. We received this case to conduct an independent review.Medicare Part D does not cover drugs that are not FDA approved for both safety and effectiveness. We determined that Hypersal 3.5% solution is not FDA approved for both safety and effectiveness by checking FDA sources. Therefore, the Plan is not required to cover Hypersal 3.5% solution. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Tacrolimus. The Plan did not grant this request. We received this case toconduct an independent review.Medicare law specifically excludes coverage for any drug under the Part D program for which paymentwould be available under Parts A or B of Medicare for that individual. Coverage is available underMedicare Part B for prescription drugs used in immunosuppressive therapy furnished to a beneficiary whohas received an organ transplant, provided the beneficiary receiving the drug was enrolled in Medicare PartA at the time of the organ transplant.The case record indicates that Tacrolimus is needed for a liver transplant performed May 1, 2002.According to Medicare enrollment records, the enrollee was determined to be entitled to Medicare Part Acoverage at the time of the transplant. Thus, the transplant is considered a Medicare covered transplant andTacrolimus is eligible for coverage under Medicare Part B. Drugs which are eligible for Part B coverageare excluded from Part D coverage by Medicare law. Therefore, our decision is that Part D Plan is notrequired to cover Tacrolimus.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 provide a tiering exception for Lorazepam 0.5 mg. The Plan did not grant this request. We received this case to conduct an independent review.A Part D Plan may establish tiered cost-sharing for drugs on its formulary of the same type (such as brand or biologic drugs when considering an exception for a brand or biologic drug). Lorazepam is classified as a Tier 1 drug on the Plan's formulary. Tier 1 drugs are not eligible for a tiering exception because they are already classified as the lowest tier on the Plan's formulary. Therefore, our decision is the Part D Plan is not required to provide a tiering exception for Lorazepam.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover HP Acthar. 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 Acthar 80 unit/ml vial. The drug is requested to treat rheumatoid arthritis. The enrollee does not satisfythe Plan's coverage criteria. You have not sufficiently addressed the Plan's coverage criteria and/or have notindicated why all alternatives required by the Plan would likely not be as effective for the enrollee as therequested drug, and/or would likely cause adverse reaction(s) or other harm to the enrollee. Our Physician'sopinion is that neither prior authorization nor prior authorization 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 HP Acthar.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Aminocaproic Acid. The Plan did not grant this request. We received this case to conduct an independent review.If a Plan maintains a specialty tier, the Plan may design its exception process so that drugs placed in the specialty tier are not eligible for a tiering exception. Aminocaproic Acid is in the specialty tier. The record indicates the Plan has chosen to exclude the specialty tier from the tiering exception process. Therefore, the Plan is not required to provide a tiering exception for Aminocaproic Acid.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Modafinil, 200 mg tablet. 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 Modafinil 200 mg tablet.The drug is requested to treat fatigue due to traumatic brain injury, which is an off-label (non-FDAapproved) use. The Medicare-approved compendia do not contain any citations to support the use of therequested drug, as prescribed, for treatment of the noted condition. Therefore, the requested drug is notbeing prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptionsrequest based on medical necessity cannot be considered because the requested drug, as prescribed, doesnot meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverageunder 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 Modafinil, 200 mg tablet for the diagnosed condition. As aresult, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. Assuch, it cannot be covered under the Medicare Part D benefit for this condition. An exceptions requestbased on medical necessity cannot be considered because this drug, as prescribed, does not meet thedefinition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to providecoverage for Modafinil, 200 mg tablet.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.