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

You asked the Plan to provide a tiering exception for Dextroamphetamine. The Plan did not grant thisrequest. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor a tiering exception for Dextroamphetamine 10 mg tab. The drug is requested to treat excessive daytimefatigue in an enrollee with multiple sclerosis. Medical records from date of service 4/30/2020 wereprovided which substantiate this diagnosis. For coverage under the prescription drug benefit, Medicarerequires that the drug prescribed be used for a medically accepted indication. Our Physician Reviewerfound that the Medicare-approved resources do contain citations to support the use of the requested drugfor treatment of the noted condition.Drugdex has a link from their monograph on the requested drug to their DRUG CONSULTS monographtitled Narcolepsy and Cataplexy - Drug Therapy; which cites the American Academy of Sleep MedicineConsensus Practice Parameters for the Treatment of Narcolepsy and other Hypersomnia's of Central Origin(Sleep. 2007 Dec 1; 30(12): 1705-1711.) which state, Based on evidence and/or long history of use in thetherapy of narcolepsy, committee consensus was that modafinil, amphetamine, methamphetamine,dextroamphetamine, and methylphenidate are reasonable options for the therapy of hypersomnia of centralorigin.Therefore, the requested drug is being prescribed for a medically accepted indication.Dextroamphetamine 10 mg tab is a generic drug on tier 4 of the Plan's formulary. The prescriber states theenrollee has tried Ritalin in the past but it was less effective. The prescriber has not indicated why alleligible lower tier alternatives on the Plan's formulary to treat the enrollee's condition (1) would not be aseffective for the enrollee as the requested drug; and/or (2) would have adverse effects for the enrollee. OurPhysician Reviewer's opinion is that tiering exception criteria are not met.Medicare rules require a Plan to grant an exception to its tiering structure whenever it determines that thehigher cost-sharing tiered drug for treatment of the enrollee's condition is medically necessary consistentwith the prescriber's statement. Our Physician Reviewer's opinion is that tiering exception criteria are notmet. Therefore, our decision is the Plan is not required to provide a tiering exception forDextroamphetamine.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Estrace, 1 mg tablet . The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for a tiering exception for Estrace 1 mg tablet.The drug is requested to treat chronic fatigue and unspecified menopausal and perimenopausal disorder. The drug is on Tier 3 of the Plan's formulary. There are no available (equivalent, branded) lower tier drugs on the Plan's formulary to treat the enrollee's condition. Therefore, the drug is not eligible for a tiering exception. Our Physician Reviewer's opinion is that tiering exception criteria are not met.Medicare rules permit a Plan to grant an exception to its tiering structure so long as there is a drug of the same type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) in a lower cost-sharing tier approved for treating the same condition that the higher cost-sharing tiered drug is being used to treat. Our Physician Reviewer's opinion is that tiering exception criteria are not met because there are no lower cost-sharing tiered drugs of the same type for treating the enrollee's condition. Therefore, our decision is the Plan is not required to provide a tiering exception for Estrace, 1 mg tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Horizant ER, 600 mg tablet, 180 per 30 days. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Horizant ER, 600 mg.Horizant ER, 600 mg is requested for ongoing treatment of the enrollee's conditions which were initially stated to be lumbar stenosis with neurogenic claudication, and generalized myalgias, which are off-label (non-FDA approved) uses. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted conditions. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted conditions. Of note, at the time of the Request for Reconsideration, the prescriber states that the enrollee uses the requested drug primarily for the diagnosis of myalgia and lumbar stenosis with neurogenic claudication; however the patient is also using it to treat his restless leg syndrome. The submitted medical records do not indicate that Horizant ER is specifically prescribed to treat symptoms related to restless leg syndrome. Therefore, based on the available documentation, Horizant ER is not being prescribed for a medically accepted indication as defined by Medicare.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. A medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia.Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicare approved compendia that support the use of Horizant ER, 600 mg tablet, 180 per 30 days for the diagnosed conditions. As a result, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be covered under the Medicare Part D benefit for these conditions. An exceptions request based on medical necessity cannot be considered because this drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage for Horizant ER, 600 mg tablet, 180 per 30 days. This decision does not concern the medical necessity of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Vraylar. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for a tiering exception for Vraylar 3 mg. Vraylar 3 mg is requested for treatment of the enrollee's condition. Vraylar 3 mg is a brand drug on Tier 4 of the Plan's formulary. There are no similar lower tier brand drugs available on the Plan's formulary to treat the enrollee's condition. Therefore, the drug is not eligible for a tiering exception. Our Physician Reviewer's opinion is that tiering exception criteria are not met.Medicare rules permit a Plan to grant an exception to its tiering structure so long as there is a drug of the same type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) in a lower cost-sharing tier approved for treating the same condition that the higher cost-sharing tiered drug is being used to treat. Our Physician Reviewer's opinion is that tiering exception criteria are not met because there are no lower cost-sharing tiered drugs of the same type for treating the enrollee's condition. Therefore, our decision is the Plan is not required to provide a tiering exception for Vraylar.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Diclofenac 1% Gel. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Diclofenac 1% Gel.Diclofenac 1% Gel is requested to treat pain in the thoracic spine/back pain, which is an off-label (non-FDA approved) use. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition. Of note, you have indicated in your Request for Reconsideration that you need the requested drug to treat left arm pain related to a shattered left humerus which is also not a medically accepted indication for the use of the requested drug.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. A medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia. Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicare approved compendia that support the use of Diclofenac 1% Gel for the diagnosed condition. As a result, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be covered under the Medicare Part D benefit for this condition. An exceptions request based on medical necessity cannot be considered because this drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage for Diclofenac 1% Gel. This decision does not concern the medical necessity of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Hizentra. The Plan did not grant this request. We received this case to conductan independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Hizentra. The drug is requested to treat R76.8 Other specified abnormal immunological findings inserum, M35.9 Systemic involvement of connective tissue, unspecified and G99.0 Autonomic neuropathy indiseases classified elsewhere, which is an off-label (non-FDA approved) use. The Medicare-approvedcompendia do not contain any citations to support the use of the requested drug, as prescribed, for treatmentof the noted conditions. Therefore, the requested drug is not being prescribed for a medically acceptedindication as defined by Medicare law. As such, an exceptions request based on medical necessity cannotbe considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part Ddrug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the notedconditions.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically acceptedindication. A medically accepted indication means a use that is approved by the FDA or a use that issupported by one or more citations in Medicare approved compendia.Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicareapproved compendia that support the use of Hizentra for the diagnosed conditions. As a result, the drug isnot being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot becovered under the Medicare Part D benefit for these conditions. An exceptions request based on medicalnecessity cannot be considered because this drug, as prescribed, does not meet the definition of a MedicarePart D drug. Therefore, our decision is that the Plan is not required to provide coverage for Hizentra.This decision does not concern the medical necessity of the requested drug. It only establishes if paymentcan be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Repatha. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Repatha 140 mg/ml syringe. The drug is requested to treat hyperlipidemia in an enrollee with clinical atherosclerotic cardiovascular disease. The enrollee does not satisfy the Plan's coverage criteria. The prescriber has not sufficiently addressed the Plan's coverage criteria and/or has not indicated why all alternatives required by the Plan would likely not be as effective for the enrollee as the requested drug, and/or would likely cause adverse reaction(s) or other harm to the enrollee. Our Physician's opinion is that neither prior authorization nor prior authorization exception criteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. A Plan must grant an exception to prior approval rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on the available documentation, our Physician Reviewer's opinion is that an exception to prior approval criteria is not met. Therefore, the Plan is not required to cover Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Omeprazole DR. The Plan did not grant this request. We received this case toconduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Omeprazole DR 20 mg, 60 per 30 days. The drug is requested to treat gastroesophageal reflux disease.The Plan limits the amount of Omeprazole DR 20 mg to 30 per 30 days. Omeprazole DR 40 mg is availableon the Plan's formulary. The prescriber has not indicated that the number of doses of the requested drugallowed by the plan would likely be ineffective in treating the enrollee's condition and/or would likelycause harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is not supported. OurPhysician Reviewer's opinion is that quantity limit exception criteria are not met.Medicare rules allow a Part D Plan to manage its formulary by covering a limited quantity of certain drugs.A Plan must grant an exception if it determines that the requested dosage is medically reasonable andnecessary, consistent with the prescriber's statement. Based on a review of the available documentation,our Physician Reviewer's opinion is that an exception to the quantity limit criteria is not met. Therefore, thePlan is not required to cover the requested quantity of Omeprazole DR.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Calcipotriene. The Plan did not grant this request. We received this case toconduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Calcipotriene. The drug was initially requested to treat basal cell carcinoma of skin, which is an offlabel(non-FDA approved) use. The Medicare-approved compendia do not contain any citations to supportthe use of the requested drug, as prescribed, for treatment of the noted condition. Therefore, the requesteddrug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, anexceptions request based on medical necessity cannot be considered because the requested drug, asprescribed, does not meet the definition of a Medicare Part D drug. Of note, a request for records was sentto you as the diagnosis for the requested drug was changed at the reconsideration level from basal cellcarcinoma of skin to actinic keratosis (and then to psoriasis). Despite the request no supporting medicalrecords to substantiate your indicated diagnoses were provided. Therefore, the requested drug is not eligiblefor coverage under Medicare Part D for the noted conditions.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically acceptedindication. A medically accepted indication means a use that is approved by the FDA or a use that issupported by one or more citations in Medicare approved compendia.Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicareapproved compendia that support the use of Calcipotriene for the diagnosed conditions. As a result, thedrug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, itcannot be covered under the Medicare Part D benefit for these conditions. An exceptions request based onmedical necessity cannot be considered because this drug, as prescribed, does not meet the definition of aMedicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage forCalcipotriene.This decision does not concern the medical necessity of the requested drug. It only establishes if paymentcan be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Favorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for Ipratropium-Albuterol 0.5-2.5 mg/3 mL andAzithromycin 250 mg received February 19, 2020. The Plan did not grant this request. We received thiscase to conduct an independent review.The Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances.In this case, you were a patient at the hospital on February 19, 2020, this was an emergency or urgent caresituation. You received Ipratropium-Albuterol and Azithromycin drug this stay. Proof of payment for thetwo self-administered drugs has been verified with the hospital. The Plan denied the request forIpratropium-Albuterol on the basis that you did not obtain prior approval. Because this was a hospital stay,you were not in a position to obtain the drugs that had been previously filled at a network pharmacy, nor werethey able to obtain prior authorization or off-formulary exception review. Since this was a one-time emergencystay, the Plan should provide an exception to their normal coverage rules. Additionally, the Plan denied therequest for Azithromycin on the basis that the National Drug Code (NDC) provided indicates theAzithromycin provided is from a re-packaged product. It is reasonable that a hospital would provide selfadministereddrugs that have been re-packaged.The Plan's out-of-network coverage rules were followed. Therefore, our decision is the Plan is required toprovide coverage and reimbursement for Ipratropium-Albuterol 0.5-2.5 mg/3 mL and Azithromycin 250mg received February 19, 2020.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Acetaminophen received January 4, 2020 at the hospital. The Plan did notgrant this request. We received this case to conduct an independent review.Medicare Part D does not cover non-prescription drugs. We checked FDA approved sources for the drug'sclassification or determined from other available resources that the drug is a non-prescription or OTC drug.Therefore, Acetaminophen is not eligible for Part D coverage, and the Plan is not required to cover it underthe Part D benefit.This decision does not address the medical necessity or appropriateness of the requested drug. It onlyestablishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

Explanation of DecisionMedicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for BD Pen Needle purchased March 23, 2020. The Plan didnot grant this request. We received this case to conduct an independent review.Medicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. If an enrolleepays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof ofpayment to ask the Plan to pay its share of the cost. For a Tier 3 drug, the Plan required a $111 copaymentamount for up to a 90 day supply from a preferred retail pharmacy and a $141 copayment amount for up toa 90 day supply from a standard retail pharmacy. Needles and syringes are on the Plan's 2020 formularyand classified as a Tier 3 item and the pharmacy used was designated as a preferred in-network pharmacy.A request for reimbursement was submitted to the Plan. In this case, the Plan provided documentationshowing that this claim was covered by the Plan at the time of purchase. The record shows that BD PenNeedle purchased March 23, 2020 was purchased for an amount that is less than or equal to the requiredcopayment amount.The case record indicates that the Plan provided coverage in accordance with the Part D contract.Therefore, our decision is the Plan is not required to provide reimbursement for BD Pen Needle purchasedMarch 23, 2020.