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

At issue is coverage for Repatha SureClick 140 milligram per milliliter subcutaneous injection pen prescribed for the treatment of hyperlipidemia in the presence of established atherosclerotic cardiovascular disease. The Part D plan denied the request for coverage because the plans prior authorization requirements were not met, as the documentation did not include confirmation that the enrollees low density lipoprotein cholesterol (LDL-C) was greater than or equal to 70 milligrams per deciliter (mg/dL) prior to starting treatment with the Repatha.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 plans prior authorization requirements for coverage of Repatha SureClick is that the drug is being used for a medically accepted indication. Additionally, there must be documentation of a pre-treatment LDL-C level greater than or equal to 70 mg/dL; the requested medication will be used in combination with maximally tolerated high-intensity statin or member is statin intolerant; and the drug must be prescribed by or in consultation with a cardiologist, endocrinologist, or lipid specialist.The records indicate that Repatha SureClick is being prescribed in the management of hyperlipidemia in the presence of established atherosclerotic cardiovascular disease in an enrollee who is statin intolerant. This is a medically accepted indication for the use of Repatha SureClick, as outlined in the Medicare approved compendia. It is documented in the medical record that the enrollee tried several statins and is statin intolerant due to myalgias. The prescriber has noted at reconsideration that the enrollees previously submitted LDL-C result of 42.6 mg/dL, obtained on March 26, 2021, was taken while the enrollee was on statin therapy. However, as noted previously, the enrollee was statin-intolerant and all statins were discontinued. The prescriber has submitted laboratory results at reconsideration that were obtained on June 25, 2021, while the enrollee was not receiving any lipid lowering therapy. The results show that the enrollees LDL-C level on June 25, 2021, prior to treatment with Repatha was 151 mg/dL. It is also noted that the prescribing physician is a cardiologist.  As such, the plans requirements for coverage of the drug have been satisfied. A physician reviewed the appeal and determined that the plan is required to cover the Repatha SureClick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexium DR 40 milligram capsules prescribed for 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 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.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 medical records do not support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Nexium DR.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Diclofenac Sodium 1% topical gel. 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 documentation indicates that Diclofenac Sodium 1% topical gel has been prescribed for the treatment of chronic right shoulder pain. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of 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 the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Pyridostigmine Bromide ER 180 milligram extended release 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 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 Pyridostigmine Bromide ER has been prescribed for the treatment of postural orthostatic tachycardia syndrome. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of 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 the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Atovaquone suspension 750 milligram/5 milliliter prescribed for babesiosis. 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. The documentation shows Atovaquone was prescribed to treat babesiosis. The Medicare approved compendia support Atovaquone plus Azithromycin (AA) was as effective as the standard treatment combination of clindamycin plus quinine (CQ) in immunocompetent adults with non-life-threatening babesiosis. The AA regimen as Atovaquone 750 milligrams (mg) every 12 hours, with Azithromycin 500 milligrams initially then 250 mg daily, each orally for 7 days. The amount requested exceeds the recommended dosing in the Medicare approved compendium for babesiosis. Additionally, the initial information provided indicates the diagnosis as Lyme's disease. There are not any medical records submitted to support a change in the diagnosis to babesiosis. Therefore, there is not a medically accepted indication for Atovaquone. A physician reviewed your appeal and determined that the plan is not required to cover Atovaquone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Ergocalciferol (Vitamin D2) 1.25 milligram (50,000 unit) capsules prescribed for vitamin D deficiency. 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. Ergocalciferol is a prescription vitamin. Prescription vitamins are excluded from coverage under Medicare Part D. Therefore, the Ergocalciferol is not eligible for coverage under Medicare Part D. 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 Lantus Solostar 100 units/milliliter pen prescribed for the enrollees condition. The Part D plan denied the request for a tiering exception.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.Lantus Solostar is a biologic on Tier 3 of the plans formulary. There are no biologics of the same type on the lower cost sharing tiers. Therefore, this biologic 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 Novolog 100 units/milliliter flexpen prescribed for the enrollees condition. The Part D plan denied the request for a tiering exception.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.Novolog is a biologic on Tier 3 of the plans formulary. There are no biologics of the same type on the lower cost sharing tiers. Therefore, this biologic 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 Enbrel 25 milligram/0.5 milliliter syringe prescribed for chronic graft versus host disease. 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 submitted documentation indicates the prescriber ordered Enbrel for chronic graft versus host disease. The Medicare approved compendia do not support the use of the biologic at issue for the enrollees condition. As the biologic was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Clobetasol 0.05% gel. 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 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. Clobetasol 0.05% gel is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all the formulary alternatives that are included in the plan to treat the enrollees condition 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 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 Sterile Water as part of a compound. 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.This is eligible for coverage under Part B. 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

At issue is Nivestym solution prefilled syringe 480 microgram/0.8 milliliter prescribed for chronic lymphocytic leukemia. 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 records submitted at the reconsideration level. The documentation shows Nivestym solution prefilled syringe 480 microgram/0.8 milliliter prescribed to treat chronic lymphocytic leukemia. The plan has prior authorization requirements for this drug that must be met before they will cover Novestym. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Nivestym. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Hizentra 20% (10 grams per 50 milliliter) solution for infusion. At determination and redetermination, the diagnoses of hypogammaglobulinemia and common variable immunodeficiency were provided.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan and any other information submitted at the reconsideration level. The submitted medical records indicate that the enrollee is receiving Hizentra in the management of hypogammaglobulinemia (reduced serum immunoglobulin levels) due to the presence of common variable immunodeficiency. While common variable immunodeficiency is a medically accepted indication for the use of Hizentra outlined in the Medicare approved compendia, the administration of Hizentra in the treatment of reduced serum immunoglobulin levels due to the presence of common variable immunodeficiency is covered under Medicare Part B. Drugs that are eligible for Part B coverage are excluded from Part D coverage by Medicare law. A physician reviewed the appeal and determined that the Part D plan is not required to cover the Hizentra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Repatha SureClick 140 milligram per milliliter subcutaneous injection pen prescribed for the treatment of hyperlipidemia in the presence of established cardiovascular disease. 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 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. Repatha is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives that are included in the plan to treat the enrollees condition 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 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 a request for coverage of non-formulary Adderall XR 30 milligram extended release capsules, 90 capsules per 30 days, prescribed for the treatment of attention deficit hyperactivity disorder. The Part D plan approved coverage for Adderall XR 30 milligram extended release capsules, 30 capsules per 30 days. However, the plan denied the request for 90 capsules per 30 days.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 request for 90 capsules of Adderall XR per 30-day supply exceeds the plan's quantity limits. The documentation does not provide clear medical rationale to support that the allowed quantity did not sufficiently address the enrollee's condition. A physician reviewed the appeal and determined that the plan is not required to cover more than 30 capsules of Adderall XR per 30-day supply.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Wegovy 0.25 milligram injection prescribed for obesity. 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.We determined that the plan is not required to cover Wegovy because it was prescribed for weight loss. Drugs to treat anorexia, weight loss, or weight gain are excluded from coverage. 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

At issue is a tiering exception request for Vancomycin Hydrochloride 500 milligram for solution. 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 documentation indicates that Vancomycin Hydrochloride has been prescribed for the treatment of keratoconjunctivitis due to acanthamoeba, keratitis, and corneal ulcer. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted conditions. Therefore, the drug is being prescribed for non-medically accepted indications and is not eligible for coverage under Medicare Part D. Since the drug is not eligible for coverage, a tiering exception in no longer applicable to this case. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Repatha SureClick 140 milligram per milliliter subcutaneous injection pen prescribed for the management of hyperlipidemia in the presence of atherosclerotic cardiovascular disease. 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 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. Repatha SureClick is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale as to why the preferred formulary alternative, Praluent, 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 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 a request for coverage of Humira 40 milligram per 0.4 milliliter subcutaneous injection kit prescribed for rheumatoid arthritis. 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 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 has prior authorization requirements that must be met before coverage of this medication will be approved. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. 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 HCL 8 milligram sublingual tablet prescribed for opioid dependence and 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 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 documentation shows Buprenorphine HCL was prescribed to treat opioid dependence and chronic pain. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mavyret 100-40 milligram tablets prescribed for chronic hepatitis C infection, genotype 2, treatment naive with compensated cirrhosis. 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.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 medical records do not support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Mavyret.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gralise 300 milligram tablet prescribed for trigeminal neuralgia. 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. The documentation shows Gralise was prescribed to treat trigeminal neuralgia. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Gralise.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nuplazid 34 milligram capsules prescribed for fragile x syndrome. 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 submitted documentation indicates the prescriber ordered Nuplazid for fragile x syndrome. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humira 40 milligram/0.4 milliliter pen injector prescribed for pyoderma gangrenosum. 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 submitted documentation indicates the prescriber ordered Humira for pyoderma gangrenosum. The Medicare approved compendia do not support the use of the biologic at issue for the enrollees condition. As the biologic was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested biologic.