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

At issue is coverage for Tobramycin 300 milligram per 5 milliliter nebulizer solution to treat Pseudomonas aeruginosa infection in an enrollee with bronchiectasis. 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 that must be put directly into the 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: Unfavorable

At issue is Kisqali 600 milligram daily dose tablet therapy 200 milligram to treat metastatic breast cancer, HR positive, HER2 negative. 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 Gemtesa 75 milligram tablet to treat overactive bladder. 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 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: Favorable

At issue is coverage for Doptelet 20 milligram tablet, 30 tablets per 30 days, to treat chronic immune thrombocytopenia (ITP). The Part D plan denied the request for coverage because the following prior authorization requirement was not met: the enrollee is scheduled to undergo a procedure.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 will be provided. At reconsideration, the prescriber has clarified that the enrollee is scheduled to undergo a procedure. The submitted progress notes validate that the enrollee is scheduled to undergo wisdom tooth extraction. The submitted medical records confirm that the plans remaining coverage requirements have been met, as well. The records show that the drug is being prescribed to treat chronic immune thrombocytopenia, which is a medically accepted indication for the drug outlined in the Medicare approved compendia. Additionally, the records indicate the following: the enrollees platelet count on November 21, 2022, prior to starting therapy with the drug in January 2023 was 31,000; the enrollee had an inadequate response to Prednisone, IVIG, Rituxan, and Promacta; the enrollee has a risk factor for bleeding (e.g., undergoing a medical or dental procedure where blood loss is anticipated); and the enrollee is 18 years of age or older. As such, the plans prior authorization requirements for this drug have been met and coverage for the drug is supported.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 Botox 200 unit per vial prescribed for chronic migraine without aura, not 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. Drugs furnished Incident To a physicians service are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Atovaquone 750 milligram per 5 milliliter suspension as prevention of pneumocystis jirovecii pneumonia in an enrollee with chronic kidney 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 Buprenorphine 2 milligram tablet sublingual to treat chronic 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.At reconsideration, the diagnosis of opioid independence was given. 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 Relyvrio 3 gram per 1 gram powder packet to treat amyotrophic lateral sclerosis. 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 Tadalafil 20 milligram tablet to treat pulmonary hypertension World Health Organization group 3 (pulmonary hypertension due to lung 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 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: Favorable

At issue is Mavyret (Glecaprevir/Pibrentasvir) 100/40 milligram tablet, 84 per 28 days to treat chronic hepatitis C without decompensated cirrhosis for a patient with prior treatment failures to Viekira (Dasabuvir Sodium/Ombitasvir/Paritaprevir/Ritonavir) and Vosevi (Sofosbuvir/Velpatasvir/Voxilaprevir). 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. American Association for the Study of Liver Disease (AASLD) supports the use of Sofosbuvir, Glecaprevir/Pibrentasvir (Mayrvet), and Ribavirin for patients who failed to respond to Sofosbuvir/Velpatasvir/Voxilaprevir because they are especially problematic to treat. A quad regimen of Sofosbuvir, Glecaprevir/Pibrentasvir, and Ribavirin for 24 weeks was successful. It is also noted that on-treatment protracted HCV RNA-negativity beyond 24 weeks might be necessary to allow for immune reconstitution and viral clearance for these most difficult-to-treat patients. Therefore, an exception to the plan's 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 Nayzilam 5 milligram nasal spray to treat seizures. 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.Nayzilam 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 Hyoscyamine Sulfate 0.125 milligram orally disintegrating tablet. 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 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.Hyoscyamine Sulfate 0.125 milligram orally disintegrating tablet has not been found by the Food and Drug Administration (FDA) to be safe and effective, and the drug product labeling has not been approved by the FDA. Drugs not approved by the FDA do not meet the definition of a Part D drug and are excluded from Part D coverage. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanz XR (extended release) 11 milligram tablet to treat amyopathic dermatomyositis. 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 Tri-Luma 0.01/4/0.05 percent cream to treat other melanin hyperpigmentation. 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.Drugs prescribed for cosmetic purposes are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Testosterone 1.62 percent gel to treat testicular hypofunction and hypogonadism. 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. At reconsideration, the prescriber provided a recent testosterone value of 140 nanograms per deciliter (ng/dL) dated March 13, 2023. This meets the criteria of a current total testosterone value less than 300 nanograms per deciliter (ng/dL).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 Methadone Hydrochloride 10 milligram tablet in the quantity of 220 tablets per 30 days to treat chronic pain severe enough to require daily, around-the-clock, long-term opioid treatment. 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 Octreotide 100 microgram per 1 milliliter injection for an enrollee status post a distal pancreatectomy for a benign neuroendocrine tumor. 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 Nexletol 180 milligram tablet to treat atherosclerotic cardiovascular disease with hyperlipidemia. 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 Cyclosporine, Modified 25 milligram capsule prescribed for kidney transplant rejection prophylaxis. 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. Additionally, we researched Medicare systems.Medicare records indicate that the enrollee has been eligible for Medicare Part A coverage from June 1, 1991, through the present. As such, the enrollee was eligible for Medicare Part A coverage when undergoing a kidney transplant on June 11, 2001. If the enrollee was eligible for Medicare Part A coverage on the date of the transplant, immunosuppressive drugs prescribed for transplant rejection prophylaxis would covered under Medicare Part B. Medicare rules state that any drug available for coverage under Medicare Part B cannot be covered under Part D. This is regardless of when, or if, the enrollee has elected to have Medicare Part B coverage. As such, the requested drug is not eligible for coverage under the Medicare Part D plan.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: Unfavorable

At issue is coverage for Mycophenolate Mofetil 250 milligram capsule prescribed for kidney transplant rejection prophylaxis. 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. Additionally, we researched Medicare systems.Medicare records indicate that the enrollee has been eligible for Medicare Part A coverage from June 1, 1991, through the present. As such, the enrollee was eligible for Medicare Part A coverage when undergoing a kidney transplant on June 11, 2001. If the enrollee was eligible for Medicare Part A coverage on the date of the transplant, immunosuppressive drugs prescribed for transplant rejection prophylaxis would covered under Medicare Part B. Medicare rules state that any drug available for coverage under Medicare Part B cannot be covered under Part D. This is regardless of when, or if, the enrollee has elected to have Medicare Part B coverage. As such, the requested drug is not eligible for coverage under the Medicare Part D plan.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: Unfavorable

At issue is coverage for Prednisone 5 milligram tablet prescribed for kidney transplant rejection prophylaxis. 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. Additionally, we researched Medicare systems.Medicare records indicate that the enrollee has been eligible for Medicare Part A coverage from June 1, 1991, through the present. As such, the enrollee was eligible for Medicare Part A coverage when undergoing a kidney transplant on June 11, 2001. If the enrollee was eligible for Medicare Part A coverage on the date of the transplant, immunosuppressive drugs prescribed for transplant rejection prophylaxis would covered under Medicare Part B. Medicare rules state that any drug available for coverage under Medicare Part B cannot be covered under Part D. This is regardless of when, or if, the enrollee has elected to have Medicare Part B coverage. As such, the requested drug is not eligible for coverage under the Medicare Part D plan.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 Fentanyl 100 microgram per hour patch with a quantity of 15 patches per 30 days to treat chronic 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 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 opioid drugs you can have on hand. The accumulated morphine milligram equivalent based on the claims summary list, are more than 200 milligram or more of morphine equivalents on hand per day. The documentation submitted includes medical records that support the drug requested is being used for chronic severe pain that requires daily, around the clock, long term opioid treatment which other options were inadequate. The enrollee is not opioid naive, will continue on non-opioid drugs in addition to the requested opioid, and the current drug regimen is helping the enrollee control the pain which increases mobility and ability with activities of daily living. There is documentation stating the enrollee will be attempting to wean down the dosage as she is able to tolerate. The prescriber has checked the enrollees history of controlled substance prescriptions via the state prescription drug monitoring program, discussed the risks with the enrollee, and an opioid agreement is in place. Therefore, an exception to the plans coverage criteria is supported. 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 Armodafinil 250 milligram tablet to treat developmental delay and fatigue. 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: Favorable

At issue is Esomeprazole Magnesium DR (delayed release) 40 milligram capsule, 180 per 90 days, to treat gastroesophageal reflux 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 limits the amount of Esomeprazole Magnesium DR (delayed release) 40 milligram capsule to 30 per 30 days. The prescriber has indicated that the number of doses of the requested drug allowed by the plan has not been effective in treating the diagnosis. Therefore, an exception to the plans quantity limit coverage criteria is medically necessary.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.