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

At issue is Inqovi 35-100 milligram tablets prescribed for acute myeloblastic leukemia, not having achieved remission. The Part D plan denied the request stating the diagnosis reported is not a medically accepted indication for the drug. 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. Per the National Comprehensive Cancer Network Category 2A, for acute myeloblastic leukemia, it is a recommendation that Inqovi can be substituted for intravenous Decitabine. However, Inqovi 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. Decitabine is on the plans formulary and there is no medical contraindication to using intravenous Decitabine. A physician reviewed your appeal and determined that the plan is not required to cover Inqovi.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tamazepam 30 milligram capsules prescribed to treat insomnia. The Part D plan denied your request.The QIC 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 QIC 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. The clinical office notes submitted are dated 10 years ago and completed by another clinician.The documentation shows the doctor prescribed Tamazepam 30 milligram capsules to treat insomnia. 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 Tamazepam 30 milligram capsules, as the prior authorization requirements have not been satisfied. 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 Gleostine 100 milligram capsules prescribed for recurrent glioblastoma. 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. According to Medicare rules, Part D drug plans do not cover drugs produced by a manufacturer who does not participate in the Medicare Gap Discount Program. The Center for Medicare and Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. According to the list, the manufacturer, NextSource Biotechnology, LLC, did not sign the agreement and does not participate in the Medicare Gap Discount Program. Therefore, we determined that the plan is not required to cover Gleostine. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for Austedo 12 milligram tablet prescribed two tablets twice daily for nonketotic hyperglycemia chorea-induced hemichorea/hemiballism. 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 the doctor prescribed Austedo to treat your nonketotic hyperglycemia chorea-induced hemichorea/hemiballism. However, the Medicare approved compendia do not support the use of the requested drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Austedo.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lumakras 120 milligram tablet prescribed for right breast invasive carcinoma. The Part D plan denied your request stating the drug is non-formulary. 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 shows the doctor prescribed Lumakras to treat your breast cancer. However, the Medicare approved compendia do not support the use of this drug for your condition. The Food and Drug Administration and Medicare compendia state that Lumakras is indicated for metastatic non-small cell lung cancer with KRAS G12 mutation after one prior systemic therapy. In addition, the citations submitted to support use are not Medicare accepted journals or are not applicable to breast cancer patients.   A physician reviewed your appeal and determined that the plan is not required to cover Lumakras.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mekinist 2 milligram oral 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 documentation shows Mekinist was prescribed to treat metastatic mutated pancreatic cancer. However, the Medicare approved compendia do not support the use of this drug for the noted condition. Mekinist is not indicated as a single agent treatment for RAF mutated pancreatic cancer. 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 Mekinist.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Rytary 36.25-145 milligram ER capsule prescribed two capsules four times per day for Parkinsons 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 records submitted at the reconsideration level.The medical records show the doctor prescribed Rytary to treat the enrollees Parkinsons disease. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The records show the enrollee has tried Carbidopa-Levodopa ER and Carbidopa-Levodopa-Entacapone which are required by the plan. Both were ineffective in the treatment of the condition. The enrollee meets step therapy criteria.A physician reviewed the appeal and determined that the plan is required to cover Rytary.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nystatin 100,000 units/gram Powder to treat erythema intertrigo. 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 Sildenafil Citrate 20 milligram tablets prescribed for pulmonary hypertension. The Part D plan denied the request as the drug was not medically indicated for the enrollees condition.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. The medical records submitted include documentation of the diagnosis of secondary pulmonary arterial hypertension. However, the records do not support a pre-treatment mean pulmonary artery pressure greater than or equal to 25 millimeters of mercury and pre-treatment pulmonary capillary wedge pressure less than or equal to 15 millimeters of mercury, and pre-treatment pulmonary vascular resistance greater than 3 Wood units. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The plans prior authorization requirements were not met. A physician reviewed your appeal and determined that the plan is not required to cover Sildenafil Citrate.  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 Ondansetron Hydrochloride 8-milligram tablet to treat nausea and vomiting due to migraine headaches. 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.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 Xifaxan 550 milligram tablets prescribed for bloating. 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 Xifaxan at issue was prescribed for bloating. 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 your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% Patch to treat bilateral primary osteoarthritis of hip, other rheumatoid arthritis with rheumatoid factor unspecified site, and dorsalgia, unspecified. 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 intermittent burning sensation at posterior neck was given. The use of the requested drug to treat the provided diagnoses are off-label uses. 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 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 Lidocaine 5% Topical Patch to treat nerve pain due to erythromelalgia. 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.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 Mesalamine Extended Release 0.375 gram capsule prescribed to treat ulcerative colitis. The Part D plan denied your 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. Mesalamine Extended Release 0.375 gram capsule is a generic drug on Tier 4 of the plans formulary. The medical records do not support that all drugs available on lower tiers to treat your condition have been tried or deemed contraindicated. The records support the enrollee was unable to tolerate Sulfasalazine but no documentation of a contraindication or intolerance to Balsalazide. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Esomeprazole Magnesium 40 milligram delayed release oral capsule. The Part D plan denied your request for a tiering exception.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.We asked the enrollees prescriber to send us information about their 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 similar medications on the lower tiers would not work for the enrollee. However, we did not receive the documentation.Esomeprazole Magnesium is a generic drug on Tier 4 of the plans formulary. The enrollees doctor did not address why the drugs available on the lower tiers of the plans formulary would not work for the enrollee. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dronabinol 5 milligram capsule prescribed for anorexia nervosa, dysphagia and lack of appetite. 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 Dronabinol was prescribed to treat the enrollees anorexia nervosa, dysphagia and lack of appetite. 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 Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Abiraterone Acetate 500 milligram tablets prescribed four times daily for prostate cancer-metastatic, castration-sensitive. 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 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. Your medical records show your doctor prescribed Abiraterone Acetate to treat your prostate cancer-metastatic, castration-sensitive. However, your medical records do not support why an exception to the plans quantity limit is medically necessary. A physician reviewed your appeal and determined that the plan is not required to cover the Abiraterone Acetate, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gilotrif 20 milligram tablets prescribed for metastatic papillary thyroid cancer. 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 your doctor prescribed Gilotrif for metastatic papillary thyroid cancer. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. There are no Medicare approved journal articles to support the use of the drug for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a prior authorization request for Abiraterone Acetate 250 milligram tablets prescribed for metastatic castrate resistant prostate cancer. The Part D plan denied coverage.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 records submitted at the reconsideration level. The enrollee satisfies the plan's coverage criteria. The prescriber submitted a statement and medical records to support the enrollee was prescribed Abiraterone Acetate for metastatic castrate resistant prostate cancer. The Medicare approved compendia support the use of Abiraterone Acetate in combination with Prednisone for the enrollees condition. In addition, the medical records submitted support the enrollee will continue on Lupron therapy.A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ajovy 225 milligram per 1.5 milliliter syringe prescribed every month for migraine without aura, not intractable, without status migrainosus. 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 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 Ajovy 225 milligram per 1.5 milliliter syringe.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Dronabinol 2.5 milligram capsules. 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 Dronabinol has been prescribed in anticipation of nausea and vomiting due to chemotherapy treatment, which has not been started yet. 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 Nexletol 180 milligram tablet prescribed for hyperlipidemia, 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 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 indicates they prescribed Nexletol 180 milligram tablet to treat hyperlipidemia, unspecified and the enrollee cannot tolerate statins. However, 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 Nexletol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue a request for coverage of Free Style Libre sensors prescribed for the treatment of diabetes. 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. Free Style Libre sensors are for use with a continuous glucose monitor. A continuous glucose monitor is classified by Medicare as durable medical equipment. Medicare rules state that Medicare Part B pays for the rental and purchase of durable medical equipment, such as continuous glucose monitors. Payment will also be made under Medicare Part B for supplies necessary for the effective use of durable medical equipment. Coverage under Part D is excluded for any item for which payment would be available under Part B. Additionally, it should be noted that continuous glucose monitor sensors are classified by the United States by the Food and Drug Administration as medical devices. As such, they do not meet the definition of a Part D drug.We determined that the Medicare Part D plan is not required to cover the Free Style Libre sensors. This decision does not address the medical necessity or appropriateness of the item. It only establishes that payment cannot be made under the Medicare Part D benefit. Please submit your request to Medicare Part B.