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

At issue is Spiriva Respimat 2.5 micrograms inhaler. The Part D plan denied the appeal request for a tiering exception.The QIC 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.Spiriva Respimat 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 Vitamin D (Ergocalciferol) 1.25 milligram capsules to treat other specified abnormal findings of blood chemistry.The QIC 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, drugs that fall into the category of vitamins and minerals are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover the Vitamin D. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil 20 milligram tablets to treat male erectile dysfunction, unspecified.   The Part D plan denied the request.  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.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not Food and Drug Administration approved, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ketoconazole 200 milligram tablets prescribed for candidiasis of vulva and vagina. 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 Ketoconazole for candidiasis of vulva and vagina. The Medicare approved compendia do not support the use of the drug at issue (in tablet formulation) 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 Xifaxan 550 milligram tablets prescribed for chronic mild diarrhea. 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 Xifaxan for chronic mild diarrhea. 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

You requested Granix 480 microgram/0.8 milliliter for neutropenia unspecified and liver transplant status. 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 Granix was prescribed to treat neutropenia unspecified and liver transplant status. However, the Medicare approved compendia do 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 Granix.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch prescribed to treat back pain with radiculopathy. The Part D plan denied the appeal request.The QIC 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 this medication.The documentation shows the doctor prescribed Lidocaine 5% patch to treat back pain with radiculopathy. The documentation provided fails to meet the criteria for the use of Lidocaine. The Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed the appeal and determined that the plan is not required to cover Lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Injectafer 750 milligram/15 milliliter vial prescribed for unknown diagnosis. 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. According to Medicare rules, drugs that fall into the category of vitamins and minerals are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover the Injectafer. There is no evidence the plan offers supplemental benefits for the Injectafer. However, this drug can be covered under Part B under certain settings. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium Gel 1% prescribed for chronic knee, back and neck pain. 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. Diclofenac Sodium Gel 1% is available over-the-counter. Non-prescription drugs are excluded from Medicare Part D drug benefits.A physician reviewed your appeal and determined that the plan is not required to cover Diclofenac Sodium Gel 1%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Divalproex Sodium 500 milligram extended release tablets 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.Divalproex Sodium ER is a generic drug on Tier 3 of the plans formulary. The prescriber submitted a supporting statement. The supporting statement did not address why the drugs available on the lower tiers of the plans formulary would not work. 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 Edarbyclor 40-12.5 milligram tablet prescribed daily for essential hypertension. 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. A physician reviewed the appeal and determined that the plan is not required to cover Edarbyclor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prevymis 480 milligram tablet prescribed for cytomegaloviral disease in an enrollee status post a kidney transplant. 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. The prescriber indicates that Prevymis 480 milligram tablet is prescribed for cytomegalovirus disease prophylaxis in this immunosuppressed, kidney transplant patient. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Prevymis.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine 15 microgram/hr patch. 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. Buprenorphine 15 microgram/hr patch is a generic drug on Tier 4 of the plans formulary. There are no generic drugs of the same type on the lower cost sharing tiers. 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 Ingrezza 80 milligram capsules prescribed to treat atypical vocal cord and diaphragmatic dystonia. The Part D plan denied the appeal request.The QIC 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 Ingrezza 80 milligram capsules to treat atypical vocal cord and diaphragmatic dystonia. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed the appeal and determined that the plan is not required to cover Ingrezza 80 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zomig 5 milligram tablets prescribed to treat migraine headaches. The Part D plan denied the appeal request.The QIC 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 the appeal and determined that the plan is not required to cover Zomig 5 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Brovana 15 microgram/2 milliliter nebulizer solution prescribed for chronic obstructive pulmonary 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 drug at issue is for use in a nebulizer in the enrollees home. 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 K-Phos No. 2 305-700 milligram tablet prescribed twice daily for low phosphorus. 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 determined that the plan is not required to cover K-Phos No. 2 because it is an electrolyte supplement. Drugs that are over-the-counter electrolyte supplements are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, they 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 formulary exception request for Oxycontin 20 milligram extended release tablets. 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 requested additional documentation from the prescriber. Specifically, we requested medical records and a prescriber statement to support all formulary alternatives were tried and failed. We did not receive the requested information.The documentation does not include medical records, a supporting statement, or evidence of a prescribed diagnosis. As it cannot be determined that the drug was 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 a request for coverage of Nulojix 250 milligram vial for intravenous infusion prescribed for kidney transplant rejection prophylaxis. 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 also researched Medicare systems and reviewed the enrollment data available.Medicare records indicate that the enrollee was enrolled in Medicare Part A and underwent a Medicare-covered kidney transplant. Since the patient was enrolled in Medicare Part A during the transplant, the Nulojix would be covered under Medicare Part B. Drugs that are eligible for Part B coverage are excluded from Part D coverage by Medicare law. As such, our decision is that the Part D plan is not required to cover the requested drug. This decision does not refer to the medical necessity of the requested drug. It only establishes that payment cannot be made under the Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jakafi 20 milligram tablets for treatment of myelofibrosis. The Part D plan denied the appeal request for a tiering exception.The QIC 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.Jakafi is a brand drug on Tier 2 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 Repatha Sureclick 140-milligrams/milliliter Solution Auto-Injector to treat atherosclerotic cardiovascular disease and 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.We asked your prescriber to send us a prescriber statement, answers to non-formulary coverage criteria, and medical records. However, we did not receive the documentation.The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary alternatives required by the plan would likely not be as effective as the requested drug for this condition, and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not medically necessary. 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 Sildenafil 20 milligram tablets to treat unspecified male sexual dysfunction. The Part D plan denied the request. 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.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not Food and Drug Administration approved, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cinacalcet Hydrochloride 30 milligram tablets prescribed for secondary hyperparathyroidism in a renal transplant patient. 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 Cinacalcet Hydrochloride for secondary hyperparathyroidism in a renal transplant patient. The enrollee is not currently receiving dialysis and does not have hypercalcemia. 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 Orphenadrine Citrate 100 milligram ER tablet prescribed every 12 hours for other muscle spasm. 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 Orphenadrine Citrate 100 milligram ER tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ongentys 50 milligram capsules prescribed to treat Parkinsons disease. The Part D plan denied the appeal request.The QIC 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 the appeal and determined that the plan is not required to cover Ongentys 50 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Cinacalcet Hydrochloride 30 milligram tablets prescribed for hypercalcemia in a renal transplant recipient with persistent hyperparathyroidism. 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 also researched Medicare systems and reviewed the enrollment data available.Medicare records indicate that the enrollee was enrolled in Medicare Part A and underwent a Medicare-covered kidney transplant. Since the patient was enrolled in Medicare Part A during the transplant, transplant-related drug therapy would be covered under Medicare Part B. Additionally, it should be noted that the enrollee had Medicare Part B end stage renal disease coverage prior to the enrollees kidney transplant on July 8, 2020.  Medicare end stage renal disease coverage does not end until 36 months after the month of the kidney transplant. Therefore, coverage of the drug may still be available under the enrollees Medicare Part B end stage renal disease coverage. Drugs that are eligible for Part B coverage are excluded from Part D coverage by Medicare law. As such, our decision is that the Part D plan is not required to cover the requested drug. This decision does not refer to the medical necessity of the requested drug. It only establishes that payment cannot be made under the Part D benefit. Please submit the request to Medicare Part B.