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

The enrollee requested Colistimethate Sodium 150 milligram for solution prescribed for the treatment of cystic fibrosis. The Part D plan denied the enrollees 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 record shows the Colistimethate Sodium is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover the Colistimethate Sodium. Please consider submitting this request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rabeprazole Sodium Delayed Release 20-milligram tablet to treat gastroesophageal reflux disease. The Part D plan denied the request. The requested drug is not on the plans formulary. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary alternatives required by the plan would likely not be as effective as the requested drug for this condition, and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not medically necessary. 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 Panzyga 10% vial prescribed as an intravenous infusion to treat mononeuritis multiplex and vasculitic neuropathy from microscopic polyangiitis. The Part D plan denied the appeal request.The QIC received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows the doctor prescribed Panzyga 10% vial to treat mononeuritis multiplex and vasculitic neuropathy from microscopic polyangiitis. However, the Medicare approved compendia do not support the use of this drug for the enrollees conditions.A physician reviewed the appeal and determined that the plan is not required to cover Panzyga 10% vial.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metolazone 5 milligram tablet prescribed for edema due to congestive heart failure. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why all other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Metolazone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300 milligrams per 2 milliliter dose pen prescribed 600 milligrams day one, then 300 milligrams every two weeks for prurigo nodularis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The doctor prescribed Dupixent 300 milligrams per 2 milliliter dose pen to treat the enrollees prurigo nodularis. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanx XR 11 milligram tablet was prescribed to treat rheumatoid arthritis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. 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 prescribers statement does not support why other drugs on the plans formulary would not work for the enrollee. This decision does not speak to the medical necessity of this drug for your condition. This decision speaks to whether your plan is required to provide coverage under Medicare rules.A physician reviewed your appeal and determined that the plan is not required to Xeljanx.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate Mofetil 500 milligram tablets prescribed for cicatricial pemphigoid. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates the prescriber ordered Mycophenolate Mofetil for cicatricial pemphigoid. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Promethazine Hydrochloride suppository 12.5 milligram prescribed for cyclical vomiting syndrome. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The prescriber indicates they prescribed Promethazine Hydrochloride suppositories to treat cyclical vomiting syndrome, an idiopathic disorder characterized by recurrent, stereotypical bouts of vomiting with intervening periods of normal or baseline health. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Promethazine Hydrochloride suppositories.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydromorphone extended release 8 milligram tablet prescribed for low back pain. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why the other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Hydromorphone extended release tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Horizant Extended Release 600 milligram tablet prescribed for other cervical disc degeneration, other intervertebral disc degeneration, and radiculopathy of the lumbar region. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The prescriber indicates the enrollee is unable to take various medications due to having an allergic reaction to various prescriptions and Horizant works well for her. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. This decision does not speak to the medical necessity of this drug for your condition. This decision speaks to whether your plan is required to provide coverage under Medicare rules.A physician reviewed your appeal and determined that the plan is not required to cover Horizant Extended Release tablet.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Pomalyst 2 milligram capsule prescribed 21 per 28 days for multiple myeloma. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The plan requires for coverage of Pomalyst that the enrollee not have progression of disease when on Pomalyst that requires change in therapy. Per National Comprehensive Cancer Network, it is a category 2A recommendation that Pomalyst can be given in combination with Elotuzumab and Dexamethasone in enrollees who have had two prior therapies including immunomodulatory agent and proteosome inhibitor. The National Comprehensive Cancer Network does not mention other previous treatments that the enrollee may have been on. Therefore, the criteria for a prior authorization have been met.A physician reviewed the appeal and determined that Pomalyst is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trulicity 1.5 milligram/0.5 milliliter pen injector prescribed as directed. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Trulicity is a biological product drug on Tier 3 of the plans formulary. There are no biological product drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Emgality solution auto-injector 120 milligram/milliliter prescribed for migraine without aura, not intractable, without status migrainosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. 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 prescribers statement does not support why other drugs on the plans formulary, with support in the medical record, would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Emgality.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Calcipotriene 0.005% ointment prescribed for atopic dermatitis, hand dermatitis, and psoriasiform dermatitis. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates the prescriber ordered Calcipotriene ointment for atopic dermatitis, hand dermatitis, and psoriasiform dermatitis. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Alunbrig 90 milligram tablet prescribed for neurofibromatosis type 2. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows Alunbrig was prescribed for an enrollee with a complicated history of neurofibromatosis type 2 with increasing pain and facial spasms. However, the Medicare approved compendia do not support the use of this drug for neurofibromatosis type 2 or for acoustic neuroma/schwannoma. The prescriber submitted an article that is not a Medicare approved journal and the prescriber cites an active clinical trial but no results are published as of yet. A physician reviewed your appeal and determined that the plan is not required to cover Alunbrig.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trelegy Ellipta 100/62.5/25 microgram aerosol powder prescribed as directed. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Trelegy Ellipta is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Relion Novolin 70-30 Vial to treat diabetes mellitus. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Relion Novolin 70-30 Vial is a brand drug on Tier 2 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is NP Thyroid 90 milligram tablets prescribed for the enrollees condition. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The drug at issue is not Food and Drug Administration approved. 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 a prior authorization request for Nexletol 180 milligram tablets prescribed for familial hypercholesterolemia. The Part D plan denied coverage.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the plans prior authorization coverage criteria were met. We received the requested documentation and included it in the review.The documentation on hand includes a physician supporting statement. The supporting statement does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Topiramate 50 milligram tablet prescribed for cerebellar ataxia. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The medical records support Topiramate 50 milligram tablet is prescribed for cerebellar ataxia. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Topiramate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone Cypionate 200 milligram per milliliter solution prescribed monthly for fatigue and low testosterone level. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we reviewed the appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available.The doctor prescribed Testosterone Cypionate to treat the enrollees fatigue and low testosterone level. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria. A tiering exception cannot be considered because the prior authorization requirements were not met.A physician reviewed the appeal and determined that the plan is not required to cover Testosterone Cypionate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ofev 150 milligram capsule prescribed twice daily for interstitial lung disease and usual interstitial pneumonia. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we reviewed the appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available.The doctor prescribed Ofev to treat the enrollees interstitial lung disease and usual interstitial pneumonia. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed the appeal and determined that the plan is not required to cover Ofev. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Somatuline Depot 120 milligram/0.5 milliliter solution prescribed for diarrhea. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates the prescriber ordered Somatuline Depot for diarrhea. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Cyclobenzaprine Hydrochloride 5 milligram tablet prescribed for lumbar radiculopathy. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The prescriber indicates they prescribed Cyclobenzaprine Hydrochloride 5 milligram tablet for chronic low back pain due to lumbar disc disease after two surgeries and the enrollee has frequent muscle spasms when having an exacerbation of symptoms. The prescriber also confirms they have assessed the risk versus benefit in prescribing the requested medication. The medical records support the enrollee has lumbar disc disease with muscle spasms of the neck. Medicare approved compendia supports the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is required to cover Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anoro Ellipta 62.5-25 micrograms inhaler prescribed to treat chronic obstructive pulmonary disease. The Part D plan denied the appeal request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Upon redetermination, the Part D plan denied the appeal request stating that the enrollees condition (environmental allergies) was not a medically accepted indication by Medicare approved compendia. The documentation on reconsideration shows the doctor prescribed Anoro Ellipta 62.5-25 micrograms inhaler to treat chronic obstructive pulmonary disease. DRUGDEX, a Medicare approved compendium, shows the diagnosis of chronic obstructive pulmonary disease is a medically accepted indication with the use of Anoro Ellipta. However, 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 medical records do not support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed the appeal and determined that the plan is not required to cover Anoro Ellipta 62.5-25 micrograms inhaler.