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

At issue is Skyrizi 150 milligram dose kit-2 syringes prescribed to treat psoriasis. The Part D plan denied the request.The QIC received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needed this medication. We did not receive the requested documentation.The documentation shows the doctor prescribed Skyrizi 150 milligram dose kit-2 syringes to treat psoriasis. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed the appeal and determined that the plan is not required to cover Skyrizi 150 milligram dose kit-2 syringes as the prior authorization requirements were not satisfied. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azathioprine 50 milligram tablets prescribed to treat chronic hypersensitivity pneumonitis.The QIC received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows the doctor prescribed Azathioprine 50 milligram tablets to treat chronic hypersensitivity pneumonitis. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed the appeal and determined that the plan is not required to cover Azathioprine 50 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nuedexta 20-10 milligram capsules. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted.The submitted documentation does not include medical records or a prescriber supporting statement. A request for information was sent to the prescriber; however, no further documentation as received. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cevimeline Hydrochloride 30 milligram capsules prescribed to treat Sjogrens syndrome. The Part D plan denied the request.The QIC received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.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 medical records do not support why other drugs on the plans formulary would not work for the enrollee.A physician reviewed your appeal and determined that the plan is not required to cover Cevimeline Hydrochloride 30 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Cosentyx 300 milligram/2 milliliter injections prescribed for plaque psoriasis. The Part D plan denied coverage.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation on hand includes a physician supporting statement. The supporting statement does not indicate that the enrollee satisfies the plan's prior authorization 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 Cinacalcet Hydrochloride 90 milligram tablets prescribed to treat end-stage renal disease with secondary hyperparathyroidism and on dialysis. The Part D plan denied the request.The QIC received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.According to Medicare rules, the requested drug is eligible for coverage under the end-stage renal disease payment bundle. Drugs which are eligible for coverage under the end-stage renal disease program are excluded from Part D coverage. We determined that the plan is not required to cover Cinacalcet Hydrochloride 90 milligram tablets. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit, but may be covered under the end-stage renal disease facility furnishing the renal dialysis services for the enrollee.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Stelara 130 milligram/26 milliliter solution prescribed for the treatment of ulcerative colitis. The Part D plan denied the enrollees request We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows the drug was supplied by the prescriber and administered to the enrollee in the prescribers office. According to Medicare rules, Part B pays for services and supplies from physician and/or office stock supply, and should be billed as part of a physician service. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined that the plan is not required to cover the Stelara. Please submit your request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aspirin EC 325 milligram tablets. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation does not contain medical records to support a prescribed diagnosis. A request for information was sent to the prescriber; however, no further documentation was received. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Breo Ellipta 200-25-micrograms Inhalation to treat lung fibrosis. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Breo Ellipta 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 condition. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Benztropine Mesylate 1 milligram tablets. The Part D plan denied the request because the prior authorization requirements for coverage of this drug were not met.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation indicates that Benztropine Mesylate has been prescribed for the treatment of extrapyramidal and movement disorder, unspecified. A request was submitted to the prescriber to clarify the diagnosis and to address the plans additional coverage requirements for this medication. The prescriber did not respond to the request. Therefore, there is insufficient documentation to determine if the drug is being used for a medically accepted indication. As such, the requested is not eligible for coverage under Medicare Part D. Since the drug is not eligible for coverage, the plans prior authorization requirements are no longer applicable to this review. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ozempic 0.25 or 0.5 milligram pen injector prescribed 1.5 milligram per 28 days to treat obesity. The Part D plan denied the request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We determined that the plan is not required to cover Ozempic because it was used to treat obesity. Drugs to treat weight gain are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 1.62% Gel Pump. At initial determination and redetermination no diagnosis was given. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows you were prescribed Testosterone 1.62% Gel Pump for an unknown diagnosis. We asked the prescriber to send us a prescriber statement, medical records verifying a medically accepted indication (diagnosis), two-morning serum testosterone laboratory reports taken prior to treatment, and prior treatment for your condition. However, we did not receive the documentation..We received no medical records from your physician. Without medical records, we cannot determine whether the requested drug was being prescribed for a medically accepted indication. 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 Ipratropium 0.5 milligrams-Albuterol 3 milligrams (2.5 milligrams base) per 3 milliliters nebulization solution prescribed to treat chronic obstructive pulmonary disease.The QIC received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows Ipatropium-Albuterol is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover Ipratropium 0.5 milligrams-Albuterol 3 milligrams (2.5 milligrams base) per 3 milliliters nebulization solution. Please submit this appeal request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Nexlizet 180-10 milligram tablets. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation indicates that Nexlizet has been prescribed for the treatment of unspecified hyperlipidemia without the presence of established atherosclerotic cardiovascular disease. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Humira citrate-free (CF) 40 grams per 0.4 milliliter subcutaneous pen-injector prescribed to administer subcutaneously every other week to treat plaque psoriasis.The QIC received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We asked the prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why the enrollee needs this medication.The medical records show the doctor prescribed Humira CF 40 grams per 0.4 milliliter subcutaneous pen-injector to treat plaque psoriasis. According to DRUGDEX, a Medicare approved compendium, the diagnosis of chronic moderate to severe plaque psoriasis is a medically accepted indication for the use of this drug.According to the clinical documentation, the enrollee has been treated for moderate plaque psoriasis on the arms, legs, trunk with Humira since January 15, 2021. The clinic note dated February 24, 2021, indicates plaque psoriasis status improved from moderate to mild with this medication therapy.  The prescriber stated that the enrollee continues to benefit from the drug.A physician reviewed your appeal and determined that the plan is required to cover Humira CF 40 grams per 0.4 milliliter subcutaneous pen-injector, as the medical documentation supports the use of this drug for the enrollees condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Azelastine 0.1% (137 microgram) nasal spray prescribed for allergic rhinitis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. Azelastine nasal spray is a generic drug on Tier 3 of the plans formulary. The prescriber has not indicated if all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug.  Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Duxipent 300-milligrams/2-milliliter Solution Pen Injector to treat atopic dermatitis. The Part D plan denied the request.  We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. 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 request for reimbursement for Synthroid 50 microgram tablets purchased on May 20, 2021. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The Part D plan has noted that the requested drug was denied coverage due to the prior authorization requirements not being satisfied. Please refer to the decision letter from the plan regarding the prior authorization denial for more details. Since the drug has been denied coverage, the plan is not required to reimburse the amount paid for the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Restasis 0.05% ophthalmic emulsion dropperettes prescribed for ocular surface disease with inflammation.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. 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 condition.  Therefore, the requested drug, as ordered, is not being used for a medically accepted indication. This decision does not speak to the medical necessity of this drug for your condition. This decision speaks to whether your plan is required to provide coverage under Medicare rules. The requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is URE-NA POW 15-Grams to treat hyponatremia. The Part D plan denied the request. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over-the-Counter (OTC) are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.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 Vraylar 1.5-milligram capsule to treat bipolar II disorder. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The 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 condition. 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 Otezla 30 milligram tablets prescribed to treat psoriatic 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 read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The prescriber indicates that a couple of plans alternative formulary drugs were tried and failed or could cause harm. In order to grant an exception for a drug not on the plans formulary, all alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the records do not support why all other drugs on the plans formulary would not work for the enrollee.A physician reviewed the appeal and determined that the plan is not required to cover Otezla 30 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq Extended Release 25 milligram tablet. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Myrbetriq Extended Release tablet is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Neupro 1 milligram per 24 hour transdermal patch prescribed for restless leg syndrome. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Neupro is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tadalafil 5-milligram tablet to treat benign prostatic hypertrophy. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The 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 condition. 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.