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

At issue is Freestyle Libre 14 day Sensor prescribed for type 2 diabetes mellitus with diabetic autonomic polyneuropathy. 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. Supplies for testing and monitoring blood glucose levels are not considered Part D drugs and may be covered under the Medicare Part B durable medical equipment benefit.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Brukinsa 80 milligram capsule to treat relapsed refractory low grade non-Hodgkin 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 documentation indicates the prescriber ordered the drug at issue for the enrollees diagnosis. The National Comprehensive Cancer Network contains a citation to support the use of the drug for small cell lymphoma for relapsed/refractory disease. As such, the submitted documentation supports the drug was prescribed for a medically accepted indication. This patient would be considered to have relapsed/refractory disease as she has progressed on Rituxan (which is also used to treat small cell lymphoma). The plan has prior authorization coverage criteria that must be met prior to approval. The clinical notes indicate there is a small cell lymphoma component present. The enrollee satisfies the Plans coverage criteria.  A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Enhertu 100 milligram intravenous solution to treat metastatic breast cancer, HR positive, low HER2 positive, IHC2+/FISH negative 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.The documentation indicates the prescriber ordered the drug at issue for the enrollees diagnosis. The Medicare approved compendia contain a citation to support the use of the drug for the noted diagnosis. The Medicare approved compendium National Comprehensive Cancer Network indicates that Enhertu is 'preferred as a single-agent for recurrent unresectable (local or regional) or stage IV (M1) human epidermal growth factor receptor 2 (HER2) IHC 1+ or 2+ and ISH negative disease, in patients who have received at least one prior line of chemotherapy in the metastatic setting that is hormone receptor negative and hormone receptor positive and endocrine therapy refractory.' As such, the submitted documentation supports the drug was prescribed for a medically accepted indication. The drug at issue is not on the plans formulary. A review of the plan's formulary indicates there are no other drugs to treat the enrollee's specific diagnosis on formulary. Therefore, an exception to the plans formulary coverage criteria is medically necessary.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 a tiering exception request for Symbicort Aerosol 160/4.5 micrograms per actuation inhaler to treat the enrollees condition. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Symbicort Aerosphere 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 Slynd 4 milligram tablet to treat dysmenorrhea and menorrhagia. 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 Lynparza 150 milligram tablets to treat metastatic squamous cell carcinoma, BRCA1 mutated. 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 Dronabinol 2.5 milligram capsule to treat anorexia associated with other symptoms and signs involving the musculoskeletal system, and rheumatoid lung disease with rheumatoid arthritis. 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 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 Ingrezza 80 milligram capsule to treat drug induced subacute dyskinesia. 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 Nurtec oral disintegrating tablet 75 milligrams to treat migraine without aura, intractable, without status migrainosus. 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 Modafinil 200 milligram tablet to treat chronic fatigue due to history of cerebrovascular accident with spastic right hemiparesis. The Part D plan denied 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 Sildenafil citrate 25 milligram tablet, 90 tablets per 90 days, to treat Raynaud's phenomenon. 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 Oyxcodone Hydrochloride 5 milligram per 5 milliliter solution to treat neoplasm related 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 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 Zolpidem Tartrate 5 milligram tablet, 45 tablets per 30 days, to treat insomnia. The Part D plan denied the request for coverage because the plans prior authorization requirements were not met. In addition, the amount requested exceeded the plans quantity limit for the drug of 30 tablets 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 plan has prior authorization requirements for this drug that must be met before coverage can be approved. The submitted documentation does not confirm that all of the plans requirements for coverage have been met. It should be noted that the prescriber/prescribers office did not indicate to the plan that the enrollee had a contraindication to the alternative drug, Doxepin. At reconsideration, it has now been noted that the enrollee has a contraindication to Doxepin. However, the prescriber/prescribers office has not indicated why Doxepin is contraindicated for this enrollee. Furthermore, the medical records submitted to the plan do not indicate that the enrollee has a contraindication to Doxepin. As such, due to the conflicting information provided and a lack of supporting medical records, it cannot be confirmed that the plans coverage requirements have been satisfied and the drug is not eligible for Part D coverage. Since the drug is not eligible for coverage, 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 Cuvitru 2 gram per 10 milliliter solution prescribed for use with a subcutaneous infusion pump for the treatment of nonfamilial hypogammaglobulinemia. 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 record shows Cuvitru is being administered to the enrollee subcutaneously through a subcutaneous infusion pump used in the home. According to Medicare rules, Medicare Part B pays for the rental and purchase of durable medical equipment, if the equipment used in the patients home. Payment may be made 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. We determined that the Medicare Part D plan is not required to cover Cuvitru. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Xarelto 15 milligram tablet prescribed as anticoagulation therapy in an enrollee with persistent 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.Xarelto 15 milligram tablet is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower tiers of the plans formulary. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewer determined that tiering exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligrams per milliliter solution auto-injector to treat hyperlipidemia and atherosclerotic cardiovascular 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.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 prescribed as anticoagulation therapy in an enrollee with chronic 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 is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower tiers of the plans formulary. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewer determined that tiering exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate Mofetil 500 milligram tablets to treat ocular cicatricial 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.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 Clonazepam 0.5 milligram tablet prescribed for focal dystonia. The Part D plan denied 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. Medicare rules state that for prescription drugs to be covered under Part D when the enrollee has elected hospice, the drug must be for treatment of a condition that is completely unrelated to the terminal condition(s) or related conditions for which hospice coverage is being provided. The submitted documentation shows Clonazepam is being used for treatment of a condition that is related to hospice. 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 Alosteron Hydrochloride 0.5 milligram tablet to treat irritable bowel syndrome with diarrhea. 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 Levalbuterol Tartrate hydrofluoroalkane (HFA) 45 microgram inhaler to treat acute bronchospasm. 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 Amphetamine/Dextroamphetamine 30 milligram extended release capsule prescribed 60 capsules per 30 days to treat attention deficit hyperactivity disorder. 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 plan limits the amount of Amphetamine/Dextroamphetamine to 30 capsules per 30 days. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the diagnosis or would be likely to cause harm. Therefore, an exception to the plans coverage criteria is not supported. 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 Deferasirox 360 milligram tablets to treat compound heterozygote hemochromatosis. 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 Sublocade 300 milligram per 1.5 milliliter solution syringe to treat opioid dependence. 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 Taltz 80 milligrams per milliliter auto-injector to treat arthropathic 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.