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

At issue is coverage for Metaxalone 800 milligram tablet. The Part D plan denied the request for coverage because the drug was not on the plans formulary and the documentation did not support a formulary exception. 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 medical records submitted at reconsideration indicate that the requested drug has been prescribed to treat muscle spasms associated with chronic musculoskeletal conditions. However, this is an off-label use 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 this condition. As outlined in the Medicare approved compendia and the Food and Drug Administration (FDA) product label, Metaxalone is indicated for the relief of discomfort associated with acute, painful musculoskeletal conditions. As such, the medical records support that the drug is being prescribed for a non-medically accepted indication, and the drug is not eligible for Part D coverage. Since the drug is not eligible for coverage, a formulary exception is not relevant to 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: Favorable

At issue is coverage for Repatha Sureclick 140 milligram per milliliter solution auto-injector. The Part D plan denied the request for coverage due to a lack of response/information from the prescriber to determine if the plans prior authorization requirements for the drug 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 medical records submitted at reconsideration indicate that the requested drug has been prescribed to treat hyperlipidemia in an enrollee with established cardiovascular disease, which is a medically accepted indication for the drug outlined in the Medicare approved compendia. Furthermore, this information satisfies the plans prior authorization requirements for the drug. As such, coverage for the drug is supported by the documentation submitted at reconsideration. 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 Cyclobenzaprine HCl 10 milligram tablets to treat muscle spasm 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 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 Nexletol 180 milligram tablets to treat other hyperlipidemia. 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 Modafinil 200 milligram tablets to treat chronic fatigue and hypersomnia. 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 Xeljanz 5 milligram tablets to treat polymyositis. 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 a 60-day supply of Oxycodone Hydrochloride ER (extended-release) tablets to treat cancer-related pain. The Part D plan approved coverage for the drug but denied the request for a 60-day supply. 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 limited to a recurring 30-day supply by the Part D plan. The submitted documentation does not support an exception to the plans quantity limit for this drug. A physician reviewed the appeal and determined that the plan is not required to cover more than a recurring 30-day supply of the requested drug, which has already been approved.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5 percent patch to treat pain from compression fracture in back. 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 Octagam 10 percent solution to treat myasthenia gravis. 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. The drug at issue must be prescribed by a neurologist.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 Sirolimus 1 milligram tablets to treat systemic lupus erythematosus. 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: Partially Favorable

At issue is coverage for Jakafi 10 milligram tablet, 1 tablet to be taken twice daily, to treat primary myelofibrosis. The Part D plan denied the request for coverage because the prescriber did not indicate that the enrollee was in one of the following risk categories as defined by the International Prognostic Scoring System (IPSS): symptomatic low-risk disease, symptomatic intermediate-1 risk disease, intermediate-2 risk disease, or high-risk disease. Additionally, the plan denied the request for a 90-day supply of 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.The prescriber statement and medical records submitted at reconsideration indicate that the enrollee has symptomatic low-risk myelofibrosis. Additionally, the documentation shows that the requested drug has been prescribed as second-line therapy after Hydroxyurea to treat the symptomatic low-risk myelofibrosis. This is a medically accepted indication for the drug as outlined in the Medicare-approved compendium, American Hospital Formulary Service Drug Information (AHFS-DI), and the National Comprehensive Cancer Network (NCCN) guidelines. Additionally, the documentation supports that the drug will be use as monotherapy for the treatment of the enrollees myelofibrosis. As such, the documentation submitted at reconsideration supports that the requested drug is being prescribed for a medically-accepted indication and that all of the plans prior authorization requirements for the drug have been met. Therefore, coverage for the drug is supported.However, while the prescriber/prescribers office initially requested a 90-day supply of the drug, the plan limits this drug to a recurring 30-day supply only. The submitted documentation does not support exceeding the plans quantity limit for the drug. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage at an amount of 60 tablets per recurring 30-day supply, which is what the prescriber requested at reconsideration. As such, the decision of the QIC is partially favorable.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Xarelto 15 milligram tablets as anti-coagulation therapy for the prophylaxis of cerebral vascular accident and systemic embolism related to 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.DRUG is a brand drug /generic drug/ biologic on Tier TIER of the plans formulary. There are no brand drugs/generic drugs/biologic of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this drug/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: Favorable

At issue is coverage for Hydrocodone-Acetaminophen 5-325 milligram tablet, 90 tablets per 30 days, 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 plan has coverage requirements for opioid-containing drugs, such as Hydrocodone-Acetaminophen. The medical records submitted at reconsideration confirm that these requirements have been satisfied. The submitted progress notes indicate that the enrollee is not opioid-naive and support the medical necessity for more than a 7-day supply of the requested drug. In addition, the prescriber statement and progress notes support that the prescriber deems it medically necessary for the enrollee to take the requested drug concurrently with the benzodiazepine drug, Temazepam. It is noted that the enrollee is taking Temazepam for insomnia and the requested drug for chronic pain. The prescriber states in the submitted progress notes, Patient is not opiate naive and appropriate trial of opioid therapy without adjunctive medications performed. Additionally, the prescriber writes, Patient was counseled and voiced understanding about dangers of using opioid medications in conjunction with other CNS [central nervous system] depressants including but not limited to Soma, TCA, sleep aids, and benzodiazepines. As such, the documentation submitted at reconsideration supports coverage for the requested drug. Furthermore, the amount requested does not exceed the plans quantity limits for the drug. 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 Trulance 3 milligram tablets to treat constipation. 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 Hydrocortisone Acetate 25 milligram suppositories to treat constipation. 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 denied the request for coverage because drugs classified as part of the Food and Drug Administrations (FDAs) Drug Efficacy Study Implementation program cannot be covered by the Medicare Part D drug benefit. These drugs are considered to be less than effective per FDA review. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Horizant ER (extended-release) 300 milligram tablet. The Part D plan denied the request for coverage because the drug was being prescribed for a non-medically accepted indication. 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 diagnosis initially provided to the plan for the requested drug was chronic pain syndrome. However, 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. At reconsideration, it has now been noted that the requested drug has been prescribed to treat diabetic peripheral neuropathy. However, the progress notes initially submitted to the plan from an office visit dated July 5, 2022, clearly indicate that the requested drug was prescribed to treat chronic pain due to cervical and lumbar radiculopathy. There is no indication in the notes that the enrollee has a diagnosis of diabetes or that the enrollee is having peripheral neuropathic pain. As such, due to conflicting information provided and a lack of medical records to validate the drug was prescribed to treat diabetic neuropathy, it cannot be determined if the requested drug is being prescribed for a 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 a tiering exception request for Ozempic 2 milligram per 1.5 milliliter solution to treat type II diabetes mellitus. 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.Ozempic 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 Dupixent 300 milligram per 2 milliliter injection solution to treat severe persistent asthma. 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 documentation supports the enrollee has oral corticosteroid-dependent asthma, and has been unable to achieve control of asthma while on maximum tolerated inhaled corticosteroid therapy in combination with a long acting beta-agonist. The enrollee is on a regimen of Ventolin inhaler with Trelegy Ellipta.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 Imbruvica 560 milligram tablet, to be used in combination with Keytruda and Rituxan, for the treatment of secondary central nervous system (CNS) lymphoma. 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 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 clinically relevant and applicable peer-reviewed 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 Diclofenac Epolamine 1.3 percent patch to treat pain due to osteoarthritis of knee. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug 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 a tiering exception request for Entresto 24-26 milligram tablet to treat chronic heart failure with reduced ejection fraction. 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.Entresto 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 tiers of the plans formulary. 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 reviewer determined that tiering exception criteria have not been met
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ambrisentan 5 milligram tablets to treat pulmonary hypertension, World Health Organization Group II. 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 Tricor 145 milligram tablet to treat pure hypercholesterolemia. 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. To grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed, or deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale with supporting documentation as to why all of the formulary alternative drugs listed by the plan 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.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.