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

You requested Pegasys 180 microgram/0.5 syringe for essential thrombocythemia, and primary myelofibrosis. 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 Pegasys was prescribed to treat essential thrombocythemia, and primary myelofibrosis. Per National Comprehensive Cancer compendia, it is a 2A recommendation for Pegasys to be used for essential thrombocythemia (all risk categories.)The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for your condition: Evidence favors efficacy for essential thrombocythemia and it is a class 2B, category B recommendation. The plan has prior authorization requirements for Pegasys that must be met before they will cover the requested drug. The plan requires that Pegasys be prescribed by a hepatologist, gastroenterologist or infectious disease specialist. In addition, the enrollee does not have a diagnosis of chronic hepatitis C nor chronic hepatitis B. The documentation provided does not satisfy the plans coverage criteria. Therefore, an exception to the plans coverage criteria is medically necessary. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Cyclobenzaprine Hydrochloride 10 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 submitted medical records indicate that Cyclobenzaprine Hydrochloride has been prescribed for the treatment of pain related to lumbar degenerative disc disease. 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 Hizentra 1 gram per 5 milliliter solution for subcutaneous infusion. 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 Hizentra for subcutaneous infusion has been prescribed for the treatment of disorder of the autonomic nervous system, autoimmune autonomic neuropathy, and small fiber neuropathy. 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. 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 Revlimid 10 milligram capsule prescribed for multiple myeloma. 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 documentation shows the enrollee is a participant in a clinical trial to determine maximum tolerated dosage of Ruxolitinib in combination with steroids and Revlimid. For Medicare coverage of routine costs with clinical trials, the  trial must not be designed exclusively to test toxicity or disease pathophysiology. Therefore, the requirements for Medicare coverage of the clinical trial including Revlimid have not been met. A physician reviewed your appeal and determined that the plan is not required to cover Revlimid.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Hydroxyzine Hydrochloride 10 milligram tablets. The Part D plan denied the request for coverage because the drug was being prescribed for a non-medically accepted indication. 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 Hydroxyzine Hydrochloride has been prescribed for the treatment of chronic interstitial cystitis. The Medicare approved compendium, DrugDex, includes an off-label citation for the use of Hydroxyzine Hydrochloride in the treatment of chronic interstitial cystitis. Therefore, the drug is being used for a medically accepted indication as outlined in DrugDex. For coverage of Hydroxyzine Hydrochloride, the plan has a prior authorization requirement for enrollees 70 years of age or older, as the American Geriatrics Society identifies the use of this medication as potentially inappropriate in older adults, meaning it is best avoided, prescribed at reduced dosage, or used with caution or carefully monitored. The requirement is that the prescriber must acknowledge that the benefit of therapy with this prescribed medication outweighs the potential risks for the enrollee. The enrollee is 74-years-old and the prescriber has acknowledge that the benefit of therapy with this prescribed medication outweighs the potential risks for the enrollee.Therefore, the drug is being used for a medically accepted indication and the plans prior authorization requirement has been satisfied. As such, coverage for the Hydroxyzine Hydrochloride can be allowed. A physician reviewed the appeal and determined that the plan is required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Ozempic 0.25-0.5 milligrams per dose pen injector.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.Ozempic 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. 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 Belbuca 75 microgram film prescribed for chronic pain. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the enrollee. However, we did not receive the documentation.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 provided does not support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed the appeal and determined that the plan is not required to cover Belbuca.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lubiprostone 24 microgram capsule prescribed daily for idiopathic constipation. The Part D plan did not make a decision.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. We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the medication was needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. However, we did not receive the documentation.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. A physician reviewed the appeal and determined that the plan is not required to cover Lubiprostone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Lidocaine 5% patches. 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 Lidocaine 5% patches have been prescribed for the treatment of bilateral hip pain due to the presence of trochanteric bursitis. 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 Vascepa 1-gram tablet to treat hypertriglyceridemia. 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 documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan, with supporting medical documentation, would likely cause harm or not be as effective as the requested drug.  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 Nuedexta 20-10 milligram capsule prescribed daily for pseudobulbar affect. 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 records submitted at the reconsideration level.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication was needed. We did not receive the documentation requested.The doctor prescribed Nuedexta to treat the enrollees pseudobulbar affect. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed the appeal and determined that the plan is not required to cover Nuedexta. 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 Humira 40 milligram per 0.4 milliliter subcutaneous injection pen. 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 medical records that were initially submitted indicate that Humira has been prescribed for the treatment of cutaneous, pulmonary, and lymph node sarcoidosis. 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. The prescriber has submitted additional documentation with an additional diagnosis of seronegative rheumatoid arthritis of multiple sites. The prescriber has also resubmitted progress notes from a physicians office visit dated June 9, 2021, that now include an addendum for the date of July 8, 2021. The addendum states, Returned call to patient. She reports that she is continuing to have joint pain and stiffness with occasional swelling at the joints including at her hands feet and ankles. Given these ongoing symptoms which she has been having she meets the diagnosis of seronegative rheumatoid arthritis. Seronegative rheumatoid arthritis means that the patient has symptoms of rheumatoid arthritis but the patients blood tests are negative for rheumatoid factor (RF) and/or anti-citrullinated peptides (CPP) antibodies. The progress notes show that the enrollees lab results from February 17, 2021, were negative for RF and CPP antibodies. As outlined in the Medicare approved compendia, a medically accepted indication for the use of Humira is in the treatment of moderate to severe rheumatoid arthritis. However, complaints of joint pain and swelling with negative RF and CPP antibodies is not clear medical record evidence of moderate to severe rheumatoid arthritis.   Therefore, the drug is being prescribed for non-medically accepted indications 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

The enrollee requested Shingrix 50 micrgram/0.5 milliliter injection prescribed for vaccination. 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 record shows the enrollee was administered the Shingrix vaccine in the physicians office. According to your plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus your required deductible, co-payment or coinsurance amount, and the difference between what the plan normally pays for the drug and what the out-of-network(providers office) charged you. If you pay the full cost of a prescription, then you 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 you paid for the vaccine and administration fee was not provided. Therefore, we determined that the plan is not required to reimburse you without the required documentation. Please submit proof of payment to your plan for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium Gel 1% prescribed for cervical dystonia. The Part D plan denied your request as the drug is not medically indicated for this condition.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 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: Favorable

At issue is Aripiprazole 5-milligram tablet.  At initial determination and redetermination the diagnosis of mixed obsessional thoughts and acts, obsessive-compulsive disorder. 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 a diagnosis of moderate episode of recurrent major depressive disorder was given. Office note of July, 2021, supports this diagnosis, and continuation of aripiprazole as adjunctive medication in addition to fluoxetine. The following citation in the American Hospital Formulary Service Drug Information (AHFS-DI), a Medicare approved compendium, supports the use of the requested drug for your condition: Aripiprazole is used orally as an adjunct to antidepressants for the treatment of major depressive disorder. Therefore, it is considered a medically accepted indication. The documentation satisfies the plans coverage criteria.  A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Drizalma 30 milligram sprinkle capsules prescribed daily for 'delirium due to known physiological condition'. 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 asked the prescriber to send us information regarding your condition. We also asked for medical records to clarify the diagnosis and to show why you need this amount of the medication. The documentation shows Drizalma was prescribed to treat your condition. The plan had approved 60 milligram sprinkle capsules for 30 days, additional 30 mg sprinkle capsules were denied. This is a de novo review, considering medically accepted indications. The Medicare approved compendia do not support the use of this drug for the enrollees condition. Therefore, a quantity exception cannot be considered for the 30 milligrams of Drizalma.A physician reviewed your appeal and determined that the plan is not required to cover Drizalma.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine Patch 5% prescribed for pain in unspecified knee. 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 that Lidocaine Patch 5% is prescribed for pain in unspecified knee. In addition, it was indicated that the enrollee does not have pain associated with diabetic neuropathy, pain due to cancer, or post-herpetic neuralgia which are the approved uses per Medicare approved compendia. 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 your appeal and determined that the plan is not required to cover Lidocaine Patch 5%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Rivastigmine (Exelon) 4.6 milligram per 24 hour transdermal patches. The Part D plan denied the request because the drug was not included on the plans formulary and the documentation did not support a formulary 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.It is noted that the plans denial reason states the formulary alternative drug that needs to be addressed by the prescriber to grant a formulary exception is Exelon patch, which is the brand-name drug for Rivastigmine patch. The prescriber has noted at reconsideration that either the brand or generic form of the drug is acceptable. However, the documentation indicates that Rivastigmine (Exelon) patches have been prescribed for memory impairment with some dementia features. 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.   The submitted medical records do not indicate that the enrollees dementia is due to the presence of Alzheimer's disease or Parkinsons disease. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. Since the drug is not eligible for coverage under Medicare Part D, a formulary exception is not applicable to this review. 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 Lidocaine Patch 5% prescribed for chronic back pain due to lumbar radiculopathy. 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 prescriber indicates that Lidocaine Patch 5% is prescribed for chronic back pain due to lumbar radiculopathy. 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 your appeal and determined that the plan is not required to cover Lidocaine Patch 5%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of First-Lansoprazole 3 milligram per milliliter oral suspension prescribed for the treatment of dyskinesia of the esophagus and dysphagia. 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 requested drug is a compounded drug that contains bulk powders. Bulk powders do not satisfy the definition of a Part D drug and are not covered by Part D. Therefore, the First-Lansoprazole is not eligible for coverage under Medicare Part D. 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.