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

At issue is coverage for Tadalafil 5-milligram tablet to treat benign prostatic hyperplasia. 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. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried and failed, or deemed contraindicated. In this case, the prescriber has not addressed the formulary alternatives required by the plan to treat the enrollees condition and provided patient specific clinical rationale as to why each formulary alternative 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 Dupixent 300-milligrams/2-milliliters solution pen-injector to treat other pruritus and bullous pemphigoid. 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.At reconsideration a diagnosis of atopic dermatitis was given, which is a medically accepted indication. However, the documentation submitted does not support a diagnosis of atopic dermatitis. As such, we are not able to determine whether the requested drug was prescribed for a medically accepted indication. Therefore, the 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 Tirosint 75-microgram capsule to treat nontoxic single thyroid nodule. 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 coverage for Opdivo 100-milligram per 10-milliliter intravenous solution to be given with Yervoy for the treatment of multifocal hepatocellular carcinoma (HCC). 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.As outlined in the Medicare approved compendia, the use of Opdivo in combination with Yervoy is indicated for the treatment of hepatocellular carcinoma in a patient that has previously been treated with Sorafenib. The prior authorization questions, answered by the prescriber/prescribers office, that were submitted to the plan indicate that the enrollee has not been previously treated with Sorafenib. Furthermore, it is noted in the medical records submitted to the plan that the enrollee has no previous treatment history.At reconsideration, it has now been noted in an unsigned, hand-written note that the enrollee did receive prior treatment with Nexavar (Sorafenib). However, no medical records have been submitted to confirm the enrollee was treated previously with Sorafenib and the medical records that have already been submitted indicate no prior treatments. As such, due to the conflicting information provided and lack of supporting documentation, 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 coverage for Yervoy 200-milligram per 40-milliliter intravenous solution to be given in combination with Opdivo for the treatment of multifocal hepatocellular carcinoma (HCC). 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.As outlined in the Medicare approved compendia, the use of Yervoy in combination with Opdivo is indicated for the treatment of hepatocellular carcinoma in a patient that has previously been treated with Sorafenib. The prior authorization questions, answered by the prescriber/prescribers office, that were submitted to the plan indicate that the enrollee has not been previously treated with Sorafenib. Furthermore, it is noted in the medical records submitted to the plan that the enrollee has no previous treatment history.At reconsideration, it has now been noted in an unsigned, hand-written note that the enrollee did receive prior treatment with Nexavar (Sorafenib). However, no medical records have been submitted to confirm the enrollee was treated previously with Sorafenib and the medical records that have already been submitted indicate no prior treatments. As such, due to the conflicting information provided and lack of supporting documentation, 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 Humira 40-milligram/0.8-milliliter pen injection kit to treat spondylosis without myelopathy or radiculopathy, site unspecified, and unspecified inflammatory spondylopathy, site unspecified. 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.Humira is a biologic on Tier 4 of the plans formulary. There are no biologics of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this 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: Unfavorable

At issue is Hydroxyzine Hydrochloride 10-milligram tablet to treat pruritis. 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 coverage for Dexmethylphenidate Hydrochloride ER 20-milligram extended-release capsule to treat attention deficit hyperactivity disorder. 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. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried and failed, or deemed contraindicated. In this case, the prescriber has not addressed the formulary alternatives required by the plan to treat the enrollees condition and provided patient specific clinical rationale as to why each formulary alternative 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: Favorable

At issue is Sildenafil 20 milligram tablet to treat pulmonary artery 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 documentation satisfies the plans coverage criteria. In the reconsideration appeal the prescriber provided a copy of a right heart cardiac catheterization report as well as office notes and an appeal letter.  The cardiac catheterization report is dated 3/24/2022 and satisfies the prior authorization requirements.  In the original electronic prior authorization to the plan the prescriber stated that the diagnosis was pulmonary artery hypertension WHO group 1. 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 Cosentyx 150-milligram/milliliter pen injector to treat plaque psoriasis. 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 Plenvu Powder packets. The case was auto-forwarded by the plan.We received the submitted documentation to perform an independent and de novo review.The submitted documentation does not include medical records or evidence of a prescribed diagnosis. Therefore, it cannot be determined if the drug was 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 Zolpidem Tartrate ER 6.25-milligram tablet to treat 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 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 a tiering exception request for Entresto 97-103 milligram tablet to treat chronic congestive heart failure. 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 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 a tiering exception request for Rytary ER (Extended-Release) 23.75 milligram-95 milligram capsules to treat Parkinson's disease. 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.Rytary ER is a brand drug on Tier 4 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 Trazadone 50-milligram tablet. The case was auto-forwarded by the plan.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 Trazodone 50-milligram tablet as a self-administered drug in the hospital. According to the plan's Evidence of Coverage, if the enrollee received a self-administered drug in the hospital and paid for it out-of-pocket, the enrollee can ask the plan to pay their share of the cost. The plan will refund the amount the enrollee paid less the normal cost sharing for the drug and any difference between the amount the hospital charged and what the plan would normally pay. In this case, we determined the plan correctly paid the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tobramycin 300 milligram per 5 milliliter nebulizer solution. 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. Based on the information provided, we determined the drug may be eligible for coverage under Part B under Medicare rules.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 Oxycodone Hydrochloride 5-milligram tablet. 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.In this case, proof of payment in the form of a receipt showing the amount that was paid for the drug was not provided. Therefore, we determined that the plan is not required to reimburse for the drug without the required documentation.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Rytary 36.25 milligram -145 milligram extended release capsule  to treat Parkinson's disease. 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.Rytary extended release is a brand drug on Tier 4 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 coverage for Nubeqa 300-milligram tablet to treat nonmetastatic castration-resistant prostate cancer. 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 initial diagnosis provided was metastatic castration-resistant prostate cancer. However, the prescriber has clarified at reconsideration that the enrollees prostate cancer is behaving like nonmetastatic castration-resistant disease, as the enrollees prostate-specific antigen (PSA) is rising while the enrollee is on androgen deprivation therapy (ADT). Furthermore, the prescriber points out that imaging completed in September 2021 showed no metastatic disease. As outlined in the Medicare approved compendia, Nubeqa is indicated for the treatment of nonmetastatic castration-resistant prostate cancer when given concurrently with a gonadotropin-releasing hormone (GnRH) analog. As such, the submitted documentation indicates the drug is being prescribed for a medically accepted indication. Furthermore, the plans prior authorization requirements for coverage of this drug are that the drug is being prescribed for the treatment of nonmetastatic castration-resistant prostate cancer and the drug must be given concurrently with a GnRH analog. Therefore, the plans coverage requirements have been satisfied as well.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 Pregabalin 75-milligram capsule to treat chronic pain 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 reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.At reconsideration, the prescriber submits the diagnosis of polyneuropathy, unspecified. However, the use of the requested drug to treat the provided diagnoses are off-label uses. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these diagnoses. 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 Xolair 150 milligrams per milliliter to treat 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 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 Lidocaine 5-percent transdermal adhesive patch to treat left hip hemiarthroplasty surgery. 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 Lidocaine 5 percent patch to treat low back pain. 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 Ubrelvy 100-milligram tablet to treat acute migraines. 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.During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support that all formulary alternatives were tried and failed, or were contraindicated. The prescriber did not respond to the request.Ubrelvy 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 and 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 reactions 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 coverage for Xarelto 10-milligram tablet prescribed for anticoagulation therapy in an enrollee with paroxysmal atrial fibrillation. The case Part D plan denied the request for coverage because the amount requested exceeded the plans quantity limit for the drug.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted.The plans quantity limit for the requested drug is 30 tablets per 30 days. While the plan stated that the amount requested exceeded their quantity limit, the plan did not include how much was requested by the prescriber in the case file. During this review, a request was submitted to the prescriber to address the plans quantity limit for the drug and to provide supporting medical records. The prescribers office responded and stated that they were no longer requesting Xarelto 10-milligram tablets, as a new prescription was written for Xarelto 20-milligram tablets. As such, an exception to the plans quantity limit is not supported. A physician reviewed the appeal and determined that the requested drug, Xarelto 10-milligram tablet, is not eligible for Part D coverage.