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

At issue is Repatha Sureclick 140 milligram per milliliter auto injector for an enrollee with atherosclerotic heart disease of native coronary artery without angina pectoris, cardiomyopathy, unspecified, and pure hypercholesterolemia, unspecified. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.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 Cresemba 186 milligram capsule to treat disseminated histoplasmosis. 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 coverage for Cyclobenzaprine Hydrochloride 10 milligram tablet to treat skeletal muscle spasms associated with chronic musculoskeletal conditions. 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 available documentation.The Part D plan is responsible for determining whether the requested drug has been prescribed for a medically accepted indication outlined in the Medicare approved compendia. 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. As noted in the Medicare approved compendia and outlined in the Food and Drug Administration (FDA) indications for the drug, Cyclobenzaprine is indicated as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions. Cyclobenzaprine should be used only for short periods (up to 2 or 3 weeks). At reconsideration, it has been noted that the enrollee has been using Cyclobenzaprine Hydrochloride since 2017 for acute muscle spasms. However, if the enrollee has been using the drug since 2017, it is not being used to treat skeletal muscle spasms associated with an acute, painful musculoskeletal condition. The submitted medical records confirm that the drug is being used to treat skeletal muscle spasms associated with chronic musculoskeletal conditions. 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 a tiering exception request for Verzenio 150 milligram tablet to treat early-stage hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative lymph node positive breast cancer. 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.This drug is being provided by the plan at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules. A physician reviewer determined that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Dupixent 300 milligram per 2 milliliter pen to treat rhinosinusitis with nasal polyposis. 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. On reconsideration prescriber statement and records indicate that the enrollee will be using the intranasal corticosteroid spray in conjunction with the Dupixent 300 milligram per 2 milliliter pen injection. Therefore, the plan criteria have been met.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 Stelara 90 milligrams per milliliter solution prefilled syringe to treat ulcerative (chronic) pancolitis with other complications. 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 Nucala 100 milligram solution reconstituted to treat nasal polyp and allergic rhinitis. 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. As this drug is not eligible for Part D coverage, it is not eligible for consideration for a formulary exception. 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 Butalbital/Aspirin/Caffeine/Codeine 50/325/40/30 milligram capsule to treat migraine, unspecified, not intractable. 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 Cyanocobalamin 1000 milligrams per milliliter solution to treat pernicious anemia. 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 use as vitamins and minerals are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.Furthermore, based on the information provided, we determined the drug may be eligible for coverage under Part B under Medicare rules.The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

A reconsideration request was auto-forwarded from the plan to review the at-risk determination. The plan has imposed a restriction on opioids for the enrollee. The enrollee must use one of the locked-in prescribers for opioids medication.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 records show the plan imposed a restriction on the enrollee. The enrollee's opioid prescriptions must be written by one of the locked-in prescribers for the enrollee. The record indicates the enrollee suffered a broken arm and was seen at the emergency department. The prescriber at issue is not one of the enrollee's locked-in prescriber. Therefore, the prescriber is not eligible to write prescriptions for opioid medications for the enrollee. A physician reviewed the appeal and determined the plans restriction is appropriate as there is a risk of obtaining an unsafe quantity of frequently abused drugs (i.e., opioids and benzodiazepines) when receiving prescriptions from multiple prescribers.In conclusion, the decision of the QIC is unfavorable.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Balversa 4 milligram tablets to treat FGFR2 W290C mutated ceruminous adenocarcinoma. 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 coverage for Testosterone 1.62 percent gel pump. The Part D plan auto-forwarded the case to us for review. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The Part D plan is responsible for determining whether the requested drug has been prescribed for a medically accepted indication outlined in the Medicare approved compendia. The submitted documentation does not include medical records or evidence of a prescribed diagnosis. During this review, a request was submitted to the prescriber to provide the diagnosis and supporting medical records and to address the plans coverage requirements for this drug. The prescriber did not respond to the request. Without a diagnosis, it cannot be established that the drug is being prescribed for a medically accepted indication. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Suprep bowel prep 17.5/3.13/1.6 grams per 177 milliliter solution for an enrollee with a personal history of colonic polyps. 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.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support all formulary alternatives were tried and failed or were contraindicated. However, we did not receive the requested information.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 Lidocaine 5 percent patch prescribed for thoracic incisional pain after thoracoscopy. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug is not eligible for coverage under Medicare Part D. This decision does not speak to the medical necessity of this drug; it speaks to whether the Part D drug plan is responsible for payment under the Centers for Medicare and Medicaid Services (CMS) rules. 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 reimbursement for Acetaminophen 500 milligram tablet. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee is requesting reimbursement for the requested drug. The plans Evidence of Coverage states, if the enrollee pays the full cost of a prescription, then they may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that was paid for the drug, whether the drug was paid for out of pocket, with primary insurance, or using a discount drug program was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amlodipine 5 milligram tablet. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee is requesting reimbursement for the requested drug. The plans Evidence of Coverage states, if the enrollee pays the full cost of a prescription, then they may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that was paid for the drug, whether the drug was paid for out of pocket, with primary insurance, or using a discount drug program was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aspirin 81 milligram delayed release and enteric coated tablet. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee is requesting reimbursement for the requested drug. The plans Evidence of Coverage states, if the enrollee pays the full cost of a prescription, then they may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that was paid for the drug, whether the drug was paid for out of pocket, with primary insurance, or using a discount drug program was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Clopidogrel 75 milligram tablet. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee is requesting reimbursement for the requested drug. The plans Evidence of Coverage states, if the enrollee pays the full cost of a prescription, then they may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that was paid for the drug, whether the drug was paid for out of pocket, with primary insurance, or using a discount drug program was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrocodone/Acetaminophen 5/325 milligram tablet. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee is requesting reimbursement for the requested drug. The plans Evidence of Coverage states, if the enrollee pays the full cost of a prescription, then they may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that was paid for the drug, whether the drug was paid for out of pocket, with primary insurance, or using a discount drug program was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydroxychloroquine 200 milligram tablet. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee is requesting reimbursement for the requested drug. The plans Evidence of Coverage states, if the enrollee pays the full cost of a prescription, then they may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that was paid for the drug, whether the drug was paid for out of pocket, with primary insurance, or using a discount drug program was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Latanoprost 0.005 percent drops (2.5 milliliter drop bottle). The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee is requesting reimbursement for the requested drug. The plans Evidence of Coverage states, if the enrollee pays the full cost of a prescription, then they may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that was paid for the drug, whether the drug was paid for out of pocket, with primary insurance, or using a discount drug program was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lisinopril 2.5 milligram tablet. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee is requesting reimbursement for the requested drug. The plans Evidence of Coverage states, if the enrollee pays the full cost of a prescription, then they may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that was paid for the drug, whether the drug was paid for out of pocket, with primary insurance, or using a discount drug program was not provided. Therefore, the reimbursement criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methocarbamol 500 milligram tablet. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted documentation shows the enrollee is requesting reimbursement for the requested drug. The plans Evidence of Coverage states, if the enrollee pays the full cost of a prescription, then they may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that was paid for the drug, whether the drug was paid for out of pocket, with primary insurance, or using a discount drug program was not provided. Therefore, the reimbursement criteria have not been met.