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

You asked the Plan to provide a tiering exception for Myrbetriq ER. 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 Myrbetriq ER. The drug is requested to treat urinary incontinence. Myrbetriq ERis a brand drug on Tier 4 of the Plan's formulary. There are no available lower tier brand drugs of the sametype on the Plan's formulary to treat the enrollee's condition. Therefore, the drug is not eligible for a tieringexception. Our Physician Reviewer'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 Myrbetriq ER.
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 provide reimbursement for Eliquis 5 mg purchased January 8, 2020. The Plan did notgrant this request. We received this case to conduct an independent review.You submitted documentation showing that you purchased Eliquis 5 mg on January 8, 2020. The claim wascovered by a primary insurance. The Part D Plan indicates they have not yet provided any coverage for theclaim as the secondary payer; however, the Plan does state they would coordinate and allow coverage ofthis claim as the secondary payer. Eliquis 5 mg is a Part D eligible drug on the Plan's 2020 Formulary. ThePlan has not provided any reason why the claim should not be processed at this time.Therefore, it is our decision that the Plan is required to recalculate coverage as secondary payer and provideany applicable reimbursement for Eliquis 5 mg purchased January 8, 2020, less any applicable copaymentamount.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Restasis. 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 Restasis. The drug is requested to treat dry eye syndrome. The drug is on tier 3 ofthe Plan's formulary. There are no available lower tier brand drugs on the Plan's formulary to treat theenrollee's condition. Therefore, the drug is not eligible for a tiering exception. Our Physician Reviewer'sopinion 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 Restasis.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Xarelto. 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 Xarelto. The drug is requested to treat atrial fibrillation. You clarified the diagnosis in the request for reconsideration dated June 29, 2020. Medical records from date of service June 25, 2020 were provided which support this diagnosis. For coverage under the prescription drug benefit, Medicare requires that the drug prescribed be used for a medically accepted indication. Our Physician Reviewer found that the Medicare-approved resources 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 medical records provided document that the enrollee tried Eliquis but had an adverse effect. Xarelto is not on the Plan's formulary. Pradaxa is on the Plan's formulary. You have 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. Therefore, an exception to the Plan's coverage criteria is not supported. Our Physician 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 requested drug is medically necessary, consistent with the prescriber's statement. Based on a review of the available documentation, our Physician Reviewer's opinion is that formulary exception criteria are not met. Therefore, the Plan is not required to cover Xarelto.
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 Repatha Pushtronex. The Plan did not grant this request. We received this caseto conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Repatha Pushtronex. The drug is requested to treat hyperlipidemia in a patient with atheroscleroticcardiovascular disease (ASCVD), status post cerebrovascular accident (CVA) in a patient with vasculardementia and statin intolerance. The enrollee satisfies the Plan's coverage criteria. Our PhysicianReviewer's opinion is that prior authorization criteria are met.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 Repatha Pushtronex.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Shingrix vaccine (NDC 58160-0828) received July 3, 2019 and PentacelActHIB component (NDC 49281-0545) received July 3, 2019 and September 3, 2019 at the provider's office. The Plan did not grant this request. We received this case to conduct an independent review.The Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances. Ifyou pay the full cost of a prescription drug out-of-pocket you can ask the Plan to pay you back. Whensubmitting a request for reimbursement, the Plan requires that you submit your receipt documenting thepayment you have made along with your reimbursement request. In this case, you submitted a request forreimbursement to the Plan for Shingrix vaccine received July 3, 2019. The case record includes includeproof of payment. The Plan denied reimbursement on the basis that the NDC 58160-0828 provided was notvalid. MAXIMUS verified using FDA sources that NDC 58160-0828 is a valid NDC eligible for coverageunder Medicare Part D.You also submitted a request for reimbursement of Pentacel ActHIB component. The Plan deniedreimbursement ton the basis that the manufacturer of the drug did not list it properly with the Food andDrug Administration (FDA), as required by Medicare. MAXIMUS verified using FDA sources that NDC49281-0545 is a valid, FDA approved NDC eligible for coverage under Medicare Part D.The Plan's out-of-network coverage rules were followed. Therefore, our decision is the Plan is required toprovide coverage for Shingrix vaccine (NDC 58160-0828) received July 3, 2019 and Pentacel AcHIBcomponent (NDC 49281-0545) received July 3, 2019 and September 3, 2019 at the provider's office.
Appeal type: Prescription Drug
Decision: Unfavorable

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

You asked the Plan to provide a tiering exception for Anoro Ellipta. 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 Anoro Ellipta 62.5-25 mcg/inh. The drug is requested to treat chronic obstructivepulmonary disease. Anoro Ellipta 62.5-25 mcg/inh is a brand drug on tier 3 of the Plan's formulary. Thereare no available lower tier brand drugs of the same type on the Plan's formulary to treat the enrollee'scondition. Therefore, the drug is not eligible for a tiering exception. Our Physician Reviewer's opinion isthat 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 in a lower cost-sharing tier approved for treating the same condition that the higher cost-sharingtiered drug is being used to treat. Our Physician Reviewer's opinion is that tiering exception criteria are notmet because there are no lower cost-sharing tiered drugs of the same type for treating the enrollee'scondition. Therefore, our decision is the Plan is not required to provide a tiering exception for AnoroEllipta.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Butalbital-APAP-Caffeine 50-325-40 mg tablet. 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 Butalbital-Acetaminophen-Caffeine 50-325-40 mg tablet.The drug is requested to treat pain due to head and neck cancer and dysphagia, which is an off-label (non-FDA approved) use. The prescriber clarified the diagnoses in the request for reconsideration dated6/29/2020. 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 Butalbital-APAP-Caffeine 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 Butalbital-APAP-Caffeine.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 Tadalafil 20 mg tablet. The Plan did not grant this request. We received thiscase to conduct an independent review.Medicare law excludes certain drugs from Part D coverage. Tadalafil is one of those excluded drugsbecause it is a sexual or erectile dysfunction drug used to treat a condition other than sexual or erectiledysfunction for which the drug has not been approved by the FDA. The record submitted by the Plan doesnot indicate that they provide supplemental coverage for Tadalafil. Therefore, the Plan is not required tocover Tadalafil.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 provide a tiering exception for Solu-Medrol. The Plan did not grant this request. We received this case to conduct an independent review.Medicare law and Plan rules do not allow tiering exceptions for non-formulary drugs being covered through a formulary exception. The documentation in the record shows that Solu-Medrol is currently being covered for the enrollee through a formulary exception. Therefore, our decision is the Plan is not required to provide a tiering exception for Solu-Medrol.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Cosentyx. The Plan did not grant this request. We received this case to conductan independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Cosentyx 300 mg. Cosentyx 300 mg at week 0, 1,2,3, and 4, then every 4 weeks, is requested fortreatment of psoriasis. The requested dosing is the standard dosing for initiation of therapy with Cosentyx.The Plan's redetermination denial letter dated June 17, 2020 states that the requested drug is limited up tothe maximum dispensing limit as a recurring 30 day supply; they do not allow a recurring supply above 30days.Per correspondence dated April 21, 2020, CMS (The Centers for Medicare and Medicaid Services) hasissued the following guidance in response to the public health emergency posed by COVID-19: Part Dsponsors must suspend all quantity and days' supply limits under 90 days for all covered Part D drugs (asdefined in 42 CFR Section 423.100) other than such limits resulting from safety edits. As such, anexception to the plan's 30 day supply limit is warranted. Our Physician Reviewer's opinion is that quantitylimit exception criteria are met.Medicare rules allow a Part D Plan to manage its formulary by covering a limited quantity of certain drugs.A Plan must grant an exception if it determines that the requested dosage is medically reasonable andnecessary, consistent with the prescriber's statement. Based on a review of the available documentation,our Physician Reviewer's opinion is that an exception to the quantity limit criteria is met. Therefore, thePlan is required to cover the requested quantity of Cosentyx.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Jardiance and Victoza. The Plan did not grant thisrequest. We received this case to conduct an independent review.Medicare rules do not require the Part D plan to grant a tiering exception for a brand or biologic drug of thesame type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) ifthe lower tier(s) on the formulary only contain(s) generic alternative drugs. Jardiance and Victoza are Tier3 brand drugs. The lower cost-sharing tier(s) only contain(s) generic alternative drugs. Therefore, ourdecision is the Plan is not required to provide a tiering exception for Jardiance and Victoza.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Nexium DR. The Plan did not grant this request. We received this case to conduct an independent review.Medicare law and Plan rules do not allow tiering exceptions for non-formulary drugs being covered through a formulary exception. The documentation in the record shows that Nexium DR is currently being covered for the enrollee through a formulary exception. Therefore, our decision is the Plan is not required to provide a tiering exception for Nexium DR.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Mometasone Furoate. 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 Mometasone Furoate 50 mcg/act. The drug is requested to treat asthma and allergy. The prescriber hasnot indicated why all alternatives required by the Plan would likely not be as effective for the enrollee asthe requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore,an exception to the Plan's coverage criteria is not supported. Our Physician Reviewer's opinion is thatformulary 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 Mometasone Furoate.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Sildenafil 20 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 Sildenafil 20 mg tablet.The drug is requested to treat pulmonary hypertension, which is an off-label (non-FDA approved) use. TheMedicare-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 Sildenafil for the diagnosed condition. As a result, the drug isnot being 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 Sildenafil.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: Favorable

You asked the Plan to cover Repatha SureClick 140 mg/ml solution. 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 requestfor Repatha SureClick 140 mg/ml solution. The drug is requested to treat hyperlipidemia and coronaryartery disease with coronary artery bypass graft surgery. Upon reconsideration, the prescribing physicianhas submitted chart notes documenting that you are intolerant of statins, with history of statin inducedmyopathy requiring treatment with Methotrexate. You satisfy the Plan's coverage criteria. Our PhysicianReviewer's opinion is that prior authorization criteria are met.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 Repatha SureClick 140 mg/ml solution.