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

At issue is Skyrizi 75 mg/0.83 ml injection to treat psoriasis vulgaris. The Part D plan denied the request. The requested drug is not on the plans formulary. We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Provider letter and journal articles are acknowledged. The Medicare approved compendia do not recognize the issues raised as contraindications. Therefore, an exception to the plans formulary coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Favorable

You requested Stivarga 40 milligram tablets prescribed as directed for the treatment of metastatic hepatocellular carcinoma. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows the physician prescribed Stivarga for the treatment of metastatic hepatocellular carcinoma, diagnosed in 2018. The enrollee had treatment with Tecentriq and Avastin with good response; however, the enrollee subsequently developed encephalopathy. The enrollee underwent two transarterial chemoembolization procedures, followed by radiation. Most recently, the enrollee had disease recurrence and began treatment with Lenvatinib; however, imaging showed disease progression. The National Comprehensive Cancer Network guidelines show that Stivarga has a category I recommendation for subsequent treatment of hepatocellular carcinoma. As such, the Medicare approved compendia support the use of the requested drug for the enrollees condition. The medical records show the enrollee experienced disease progression while being treated with Lenvatinib, which is in the same drug class as Sorafenib (VEGF inhibitor). Therefore, an exception to the plans prior authorization criteria for prior treatment with Sorafenib is medically necessary for this enrollee.A physician reviewed your appeal and determined that the plan is required to cover Stivarga.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick Solution 140 milligrams/milliliter Auto Injector to treat hyperlipidemia. The Part D plan denied the request. The requested drug is not on the plans formulary. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported.Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cuvitru 10-grams/50-milliliter Vial to treat nonfamilial hypogammaglobulinemia. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The 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 condition. Therefore, the requested drug 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 Enbrel SureClick 50 milligram/milliliter pen injector prescribed for rheumatoid arthritis. The Part D plan denied your request for a tiering exception. We received an expedited reconsideration request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Enbrel SureClick is a brand drug on Tier 5 of the plans formulary. 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 reviewed your appeal and determined that the plan is not required to grant a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 2.5 milligram capsules prescribed as directed for anorexia in an enrollee with spastic quadriplegic cerebral palsy. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The use of the requested drug to treat the provided diagnoses 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 these conditions. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and  determined that the plan is not required to cover the Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Welchol 625 milligram tablet to treat diarrhea and abdominal pain. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The 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 condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Modafinil 200 milligram tablet, 2 tablets every morning, to treat fatigue due to multiple sclerosis. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.At reconsideration, the prescriber states the enrollee has a diagnosis of obstructive sleep apnea. However, the medical records do not support this diagnosis. The use of the requested drug to treat the provided diagnosis of fatigue due to multiple sclerosis 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 requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Methylphenidate Hydrochloride 20 milligram tablets. 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.The documentation indicates that Methlyphenidate Hydrochloride has been prescribed for idiopathic hypersomnolence. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the Methlyphenidate Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dronabinol 2.5 milligram capsule prescribed as directed for appetite stimulation for treatment of anorexia. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.No medical records were provided by the prescriber. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover the Dronabinol because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue a tiering exception request for Budesonide EC 3 milligram capsules prescribed for microscopic colitis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Budesonide EC is a generic drug on Tier 4 of the plans formulary. The prescriber has not addressed all drugs on the lower tiers of the plans formulary to treat the noted condition, and indicated that they have been tried and failed, or are contraindicated. A physician reviewed the appeal and determined that the plan is not required to cover the Budesonide EC at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Symbicort aerosol 160/4.5 micrograms/ACT prescribed as directed for asthma. The Part D plan denied your request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Symbicort is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers of the plans formulary. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that this drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lyrica 75 milligram capsule twice daily to treat right lower limb lesion of lateral popliteal nerve. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The 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 condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Colesevelam Hydrochloride 625 milligram tablets. 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.The documentation indicates that Colesevelam Hydrochloride has been prescribed for short bowel syndrome and bile acid diarrhea. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the noted conditions. Therefore, the drug is being prescribed for non-medically accepted indications and is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the Colesevelam Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nulojix 250 milligram for solution prescribed for kidney transplant rejection. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows the enrollee had a kidney transplant on October 28, 2020. According to Medicare enrollment records, the enrollee was entitled to Medicare Part A coverage at the time of the transplant. Therefore, the transplant is considered a Medicare covered transplant and Nulojix is eligible for coverage under Medicare Part B. Medicare Part B covers prescription drugs used in immunosuppressive therapy furnished to an enrollee who has received an organ transplant. Drugs which are eligible for Part B coverage are excluded from Part D coverage by Medicare law. We determined that the Medicare Part D plan is not required to cover Nulojix. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methylphenidate Hydrochloride 5 milligram tablet. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The physician submitted a supporting statement. The prescriber statement indicates that Methylphenidate Hydrochloride is prescribed for stroke recovery. Additional diagnoses include fatigue and major depressive disorder. However, the Medicare approved compendia do not support the use of this specific drug for the enrollees conditions.A physician reviewed your appeal and determined that the plan is not required to Methylphenidate Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Avycaz 2.5 grams/vial prescribed every 8 hours for two weeks to treat cellulitis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. Medicare approved compendia does not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Avycaz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ondansetron Hydrochloride 4 milligram tablets. 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. This includes any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. The visit notes submitted were in reference to a fall with wound care. The documentation is insufficient to determine if the drug is bring prescribed for a medically accepted indication. A physician reviewed your appeal and determined that the plan is not required to cover Ondansetron Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliquis 5 milligram tablets for treatment of the enrollees condition. The Part D plan denied your request for a tiering exception.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Eliquis 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 condition. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tobramycin 300 milligram/5 milliliter nebulizer solution prescribed as directed for pseudomonas aeruginosa infection. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.No medical records were provided by the prescriber to support the diagnosis listed. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Tobramycin nebulizer solution.
Appeal type: Prescription Drug
Decision: Favorable

You requested a tiering exception for Eliquis 2.5 milligram tablets prescribed to treat your condition. The Part D plan indicated they approved your request for a tiering exception; however, the decision was not timely.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows the plan has granted your tiering exception request for Eliquis 2.5 milligram tablets. The approval was not made timely. The requested drug has been approved coverage at Tier 1 under Medicare Part D from January 1, 2021, through December 31, 2021.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Amlodipine valsartan 5 milligram-320 milligram tablets prescribed for unknown diagnosis. The Part D plan was unable to review your case timely and auto-forwarded your request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows you were in the initial coverage stage of the Part D benefit when this drug was purchased. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charged you. The record shows the plan paid its share of the cost for the Amlodipine valsartan and the remaining amount was your copay for a tier 1 drug filled at a preferred pharmacy. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Restasis 0.05% droperette prescribed for unknown diagnosis. The Part D plan was unable to review your case timely and auto-forwarded your request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows you were in the initial coverage stage of the Part D benefit when this drug was purchased. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charged you. The record shows the plan paid its share of the cost for the Restasis and the remaining amount was your copay for a tier 3 drug filled at a preferred pharmacy. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ventolin HFA 90 microgram aerosol inhaler prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The plan submitted documentation that shows you were still in the deductible stage of the Part D benefit when you were provided the self-administered drug during an emergency room visit. Your plans Evidence of Coverage states that you are responsible for the full cost of covered drugs until the deductible amount is satisfied. We determined this drug was paid correctly and no reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Prochlorperazine 10 milligram tablets prescribed for nausea. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. 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 record shows Prochlorperazine is being used for treatment of a condition that is related to hospice. However, your drug appears to be eligible for Part A coverage. We determined that the Part D plan is not required to cover the Prochlorperazine. Please submit your request to Medicare Part A. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.