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

At issue is coverage for Ipratropium/Albuterol 0.5/3.0 milligram per 3 milliliter nebulizer solution to treat chronic obstructive pulmonary disease with current exacerbation including shortness of breath and hypoxia. 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 documentation indicates that the requested drug is going to be used with a nebulizer. Medicare classifies nebulizers as durable medical equipment. Medicare rules state that Medicare Part B pays for the rental and purchase of durable medical equipment. Additionally, payment will be made under Medicare Part B for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals, which must be put directly into the equipment to achieve the therapeutic benefit of the durable medical equipment. Coverage under Part D is excluded for any drug for which payment would be available under Part B. As such, the requested nebulizer drug is excluded from Part D coverage.This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit. Please submit the request for coverage through Medicare Part B.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Xifaxan 550 milligram tablet to treat hepatic encephalopathy in an enrollee with cirrhosis of the liver. 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 prescriber clarified the diagnosis in the request for reconsideration. Medical records from date of service July 25, 2022, were provided which support the newly provided diagnoses of cirrhosis of the liver and hepatic encephalopathy.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 Hydroxyzine Hydrochloride 25 milligram tablet to treat anxiety-related insomnia. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.The 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 Budesonide/Formoterol Fumarate 80/4.5 microgram per actuation aerosol inhaler to treat poorly controlled 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 requested drug is not on the plans formulary. In order 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 documentation does not support why the formulary alternative drugs listed 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 Stelara 90 milligram per milliliter injection syringe to treat plaque psoriasis and hidradenitis suppurativa. 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 approved. The submitted documentation does not satisfy the plans coverage criteria.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Kisqali 600 milligram tablets to treat metastatic hormone receptor positive, human epidermal growth factor receptor-2 negative breast cancer. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliquis 5 milligram tablet for thromboembolism prophylaxis in a member with atrial fibrillation. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. Eliquis 5 milligram tablet is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this drug is not eligible for a tiering exception. A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Modafinil 100 milligram tablet to treat the motor and non-motor symptoms associated with Parkinsons disease. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.The use of the requested drug to treat the noted condition is an off-label use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Arikayce 590 milligrams per 8.4 milliliter suspension to treat Mycobacterium abscessus infection without evidence of a positive sputum culture after at least 6 consecutive months of a multidrug background regimen therapy. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Pregabalin 300 milligram capsule, 120 capsules per 30 days. The Part D plan denied the request for coverage because the provided diagnosis was not a medically accepted indication for the drug. Additionally, the amount requested exceeded the plans quantity limit for the drug of 60 capsules per 30 days. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.The submitted medical records indicate that the requested drug has been prescribed to treat neuropathic pain due to mitochondrial myopathy. 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, the prescriber has noted on the reconsideration request form that the drug has been prescribed to treat fibromyalgia due to mitochondrial myopathy. However, no medical records have been submitted to support this additional/new diagnosis and the previously submitted progress notes do not indicate the enrollee has fibromyalgia. Due to the conflicting information provided and a lack of supporting medical records, it cannot be determined if the requested drug is being prescribed for a medically accepted indication and coverage for the drug is not supported. Since coverage is not eligible for the drug, the plans quantity limit is not relevant to this review. 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 Desoximetasone 0.05 percent ointment to treat spongiotic dermatitis in an enrollee with cutaneous T-cell lymphoma. 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 Rhopressa 0.02 percent ophthalmic solution to treat ocular hypertension. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Promethazine Hydrochloride 25 milligram tablet to treat nausea and vomiting associated with migraine headache. The Part D plan denied the request.  We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lyrica 75 milligram capsule to treat lumbar spinal stenosis with neurogenic claudication and right foot drop. 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 Cibinqo 100 milligram tablet to treat atopic dermatitis. 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 not 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 as to why the formulary alternative drug 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vygart 400 milligrams per 20 milliliters, 1000 milligrams once a week to treat myasthenia gravis, acetylcholine receptor positive, refractory. The case was auto-forwarded by the Part D plan. 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 Vilazodone 20 milligram tablet to treat major depressive disorder. The case was auto-forwarded by the plan.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 has not indicated that all alternatives required by the plan have been tried and failed, or why the plans required step therapy drugs would likely not be as effective as the requested drug. A physician reviewer determined that neither step therapy nor step therapy exception criteria are met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cresemba 186 milligram capsules to treat chronic myelomonocytic leukemia and graft versus host disease in an enrollee with a stem cell transplant. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5 percent patch prescribed to reduce tendon swelling and pain for left foot tendonitis. 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: Favorable

At issue is Botox 100 unit vials with a quantity of a total of 200 units to treat dystonia of the feet. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the enrollee has a diagnosis that supports a medically accepted indication for the requested drug and has satisfied the plans prior authorization coverage criteria. We received additional documentation and included it in the review.The documentation satisfies the plans coverage criteria. The prescriber indicates this is a new medication and not continuation of care. The medical records support the reported diagnosis of limb dystonia. The prior authorization requirements submitted by the plan show that the drug cannot be used for cosmetic reasons and indications are all Food and Drug Administration approved indications with no other restrictions except for other diagnoses. 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 Ibrance 125 milligram tablets to treat metastatic breast cancer, in combination with Letrozole, unknown HER2 status. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. Medicare-approved compendia do not contain any citations to support the use of the requested drug as prescribed, for treatment of the noted diagnosis. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Meclizine Hydrochloride 25 milligram tablet. The Part D plan denied the request for coverage because the plan could not determine if the prior authorization requirements for this drug were met due to a lack of information/response from the prescriber. 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.During this review, a request was submitted to the prescriber to address the plans coverage requirements for this drug, including the enrollees diagnosis, and to provide supporting medical records to confirm that the coverage requirements were met. The prescribers office called and stated the diagnoses for the requested drug were dizziness and vertigo. However, no medical records were submitted, as requested. Additionally, the prior authorization requirement questions were not answered and returned, as requested.The use of the requested drug to treat vertigo is a medically accepted indication for the drug outlined in the Medicare approved compendia. However, the plan has prior authorization requirements that need to be met before the drug can be approved. There is not sufficient documentation available to confirm whether the plans coverage requirements have been satisfied. 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 Humalog 100 unit per milliliter insulin pen prescribed for an unspecified diagnosis. The Part D plan denied the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for the requested drug was approved and coinsurance was charged to the enrollee at the point of sale. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The plan indicates the enrollee was in the catastrophic coverage stage and a coinsurance was applied when this tier 6 drug was purchased. Therefore, we determined no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Tetanus Diphtheria and Pertussis (TDAP) vaccine prescribed for vaccination. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the vaccine at the prescriber's office. The plans Evidence of Coverage states that payment for vaccines including administration fee is required up front from the enrollee when provided at an out of network pharmacy or prescribers office. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The submitted documentation includes a billing statement from the prescribing physician indicating full payment was made for the vaccine and administration fee. The information shows a valid National Drug Code (NDC) for the vaccine and the provider's National Provider Identifier (NPI) number. Therefore, the reimbursement criteria have been met.