Persius/hicric huggingface dataset:
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 hypercholesterolemia. 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 all of the formulary alternatives 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 Buprenorphine Hydrochloride 8 milligram sublingual tablets. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation indicates that Buprenorphine Hydrochloride sublingual tablets have been prescribed for chronic pain management due to the presence of spondylosis in the lumbosacral and cervical regions. 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 Apokyn 10 milligram/milliliter cartridge prescribed 30 cartridges for 14 days for Parkinsons disease. 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 Apokyn was prescribed to treat Parkinsons disease. However, the medical records do not support why an exception to the plans quantity limit is medically necessary.    The following citation in DrugDex, a Medicare approved compendium states, 'There is limited experience with dosing more than 5 times/day or total daily doses greater than 2 mL (20 mg).'A physician reviewed your appeal and determined that the plan is not required to cover the Apokyn, 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 Sildenafil Citrate 10 milligrams per milliliter prescribed 0.5 milliliter by mouth three times daily for secondary pulmonary 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.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 received the prescribers statement and included it in our review. The records show the doctor prescribed Sildenafil Citrate to treat the enrollees secondary pulmonary hypertension. The medical records provided do not support the specific diagnosis of pulmonary arterial hypertension, WHO group I. The drug is being requested for a diagnosis that is not a medically accepted indication.A physician reviewed this appeal and determined that the plan is not required to cover Sildenafil Citrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Testosterone 1.62% gel pump. 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 Testosterone has been prescribed for the treatment of testicular hypofunction and unspecified testicular hypogonadism. 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 Lidocaine 5% patch prescribed for low back pain. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation does not contain a physician supporting statement or medical records. A request for information was sent to the prescriber; however, no further documentation was received. As it cannot be determined that the drug was 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 Tacrolimus 1 milligram capsule prescribed for kidney and pancreas transplant rejection prophylaxis. The Part D plan denied your request.We received a 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 received a kidney and pancreas transplant on November 11, 2008.  According to Medicare enrollment records, the enrollee was entitled to Medicare Part A coverage at the time of the transplant. Therefore, the transplant is considered a Medicare covered transplant and Tacrolimus is eligible for coverage under Medicare Part B. Medicare Part B covers prescription drugs used in immunosuppressive therapy furnished to an enrollee who has received an organ transplant. Drugs which are eligible for Part B coverage are excluded from Part D coverage by Medicare law. We determined that the Medicare Part D plan is not required to cover Tacrolimus. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a quantity limit exception for Buprenorphine-Naloxone 8-2 milligram sublingual tablets prescribed four times daily for opioid dependence. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation does not contain a physician supporting statement or medical records. A request for information was sent to the prescriber; however, no further documentation was received. As it cannot be determined that the drug was prescribed for a medically accepted indication, a quantity limit exception cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug for a quantity limit greater than the plans allowance.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rybeisus 14 milligram tablets. 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 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.Rybeisus 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 NP Thyroid to treat hypothyroidism. 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 physician prescribed NP Thyroid. The Part D plan denied the requested drug stating that the provided diagnosis was a non-medically accepted indication. However, NP Thyroid has not been approved by the United States Food and Drug Administration. Non-Food and Drug Administration approved drugs are excluded from Medicare Part D coverage. The QIC has determined that the requested drug is excluded from Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Latuda 20 milligram tablets prescribed daily for major depressive disorder. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates the Latuda at issue was prescribed for major depressive disorder. 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

You requested Ibrance 75 milligram capsules. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted.The submitted documentation does not include medical records to support a covered diagnosis. A request for information was sent to the prescriber; however, no further documentation was received. Medical records were requested but not provided.  As it cannot be determined that the drug was 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 Linzess 145 microgram capsules. 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 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.Linzess 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 Arikayce 590 milligram/8.4 milliliter nebulizer solution prescribed for mycobacterium avium complex infection. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates the drug is to be used 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 Mavyret 100/40 milligram tablets prescribed as directed for chronic hepatitis, unspecified. The Part D plan denied the enrollees request.We received the case to perform an independent and de novo review. To make our decision, we read the enrollees 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 also researched Medicare systems and reviewed the enrollment data available.The enrollees medical records show your doctor prescribed Mavyret to treat your chronic hepatitis, unspecified. The enrollees 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 your appeal and determined that the plan is not required to cover Mavyret.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Opsumit 10 milligram tablets prescribed for pulmonary hypertension in an enrollee with obstructive sleep apnea syndrome. 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 cardiac catheterization report from date of service 6/18/2021 was provided, which substantiated a diagnosis of moderate pulmonary hypertension, with a mPAP of 35 mmHg and an elevated PCWP greater than 15 mmHg.  Medical records from date of service 6/3/2021 substantiate the diagnoses of pulmonary hypertension and obstructive sleep apnea syndrome.  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 Sodium Phenylbutyrate 3 grams per teaspoon powder prescribed for amyotrophic lateral sclerosis. 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 shows the doctor prescribed Sodium Phenylbutyrate to treat the enrollees amyotrophic lateral sclerosis. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Sodium Phenylbutyrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil Citrate 20 milligram tablet prescribed for pulmonary arterial hypertension. The Part D plan denied your request because the drug was not used for a medically accepted indication.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. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We received the documentation and included it in our review. Your medical records show your doctor prescribed Sildenafil Citrate to treat your pulmonary arterial hypertension. The Medicare approved compendia support the use of Sildenafil Citrate for this condition. However, your 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 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 Corlanor 5 milligram tablets prescribed twice daily for congestive heart failure in an enrollee with an ejection fraction greater than 35%. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates the Corlanor at issue was prescribed for congestive heart failure in an enrollee with an ejection fraction greater than 35%. 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: Favorable

You requested Lenvima 20 milligram/day capsules prescribed for renal cell carcinoma. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates your doctor prescribed Lenvima in combination with Keytruda for recently diagnosed clear cell renal cell carcinoma. Medical records from date of service 6/30/2021 were provided.  These medical records document that the enrollee has Stage IV disease involving the lung. The enrollee has not had prior chemotherapy. The following citation in NCCN, a Medicare approved compendium, supports the use of Lenvima in combination with Keytruda for the enrollee's condition. NCCN states that Lenvima is 'Therapy for relapse or stage IV disease in combination with pembrolizumab (preferred) as first-line therapy for clear cell histology and favorable or poor/intermediate risk.'Therefore, it is considered a medically accepted indication.The documentation does not satisfy the plans coverage criteria. The plans coverage criteria state that you need to use Lenvima in combination with Everolimus.  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 Dupixent solution 300 milligram/2 milliliter pen-injector prescribed for dyshidrotic eczema and dermatofibroma. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication.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 Medicare approved compendia supports the use of Dupixent for atopic dermatitis. However, 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 you. A physician reviewed your appeal and determined that the plan is not required to cover Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollee requested Hydralazine 20 milligram injection for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows the enrollee was given Hydralazine while in the hospital emergency room. The claim was submitted and processed for an amount that is less than or equal to the required copayment amount. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the out-of-network provider charged. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the copay. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch prescribed for unspecified pain and attention-deficit hyperactivity disorder. 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 Lidocaine 5% patch was prescribed to treat the Enrollees unspecified pain and attention-deficit hyperactivity disorder. 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 Lidocaine.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollee requested Demadex 20 milligram for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows the enrollee was given Demadex while in the hospital emergency room. The claim was submitted and processed for an amount that is less than or equal to the required copayment amount. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the out-of-network provider charged. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the copay. We determined this drug was paid correctly and no further reimbursement is required by the plan.