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

At issue is Humira 40 milligrams per 0.4 milliliters pen-injector kit prescribed to treat the enrollee with the diagnosis of granuloma annulare. The Part D plan denied the appeal 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 Humira 40 milligrams per 0.4 milliliters pen-injector kit to treat granuloma annulare. 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 Humira 40 milligrams per 0.4 milliliters pen-injector kit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha 140 milligrams per milliliter syringe prescribed to treat the enrollees condition. The Part D plan denied the appeal 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.Repatha is a biological drug on Tier 4 of the plans formulary. There are no biological 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 a request for coverage of Fycompa 2-milligram tablets. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any records submitted at the reconsideration level. The documentation indicates that Fycompa has been prescribed for the treatment of orthostatic tremor. 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 Shingrix vial kit prescribed for vaccination. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 requested drug for vaccination in the prescriber's office. The plans Evidence of Coverage states, if the enrollee pays the full cost of a prescription, then they 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 was paid for the drug was not provided. Therefore, we determined that the plan is not required to provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Restasis 0.05 percent ophthalmic dropperette prescribed for the treatment of dry eye syndrome. 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.Restasis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier level. The drug will continue to be covered at the Tier 3 copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement of $860.99 for the purchase of Atovaquone 750-milligram per 5-milliliter oral suspension for the date of service of July 31, 2021. The Part D plan denied the request for reimbursement.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 Part D plan has denied coverage for the drug due to the prior authorization requirements not being satisfied. Please refer to the decision letter from the plan regarding the prior authorization denial for more details. Since the drug has been denied coverage, the plan is not required to reimburse the amount paid for the drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq extended-release 50 milligram tablets prescribed to treat the enrollees condition. The Part D plan denied the appeal 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.Myrbetriq 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 Bystolic 10 milligram tablet to treat hypertension. The Part D plan denied the request.  The requested drug is not on the plans formulary. 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.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 Octreotide Acetate 100-micrograms/milliliter Solution to treat hepatorenal syndrome. 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 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 Otezla 30 milligram tablets prescribed to treat an enrollee with the diagnosis of oral and cutaneous lichen planus. The Part D plan denied the appeal 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 Otezla 30 milligram tablets to treat oral and cutaneous lichen planus. 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 Otezla 30 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Phenelzine Sulfate 15-milligram tablets prescribed daily for the enrollees condition. 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.Phenelzine Sulfate is a generic drug on Tier 3 of the plans formulary. The supporting statement from the prescriber does not address why all alternative lower-tier medications on the plans formulary would not work for the enrollee. All drugs on lower tiers have not been tried. 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 the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Arikayce 590 milligram per 8.4 milliliter nebulizer solution, 235.2 milliliters per 28 days, prescribed for the treatment of Mycobacterium avium complex lung disease caused by Mycobacterium intracellulare infection. The Part D plan denied the request for coverage because there was not confirmation that Arikayce will be used in conjunction with a background multidrug regimen.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 indicates the enrollee is being treated for Mycobacterium avium complex lung disease and has experienced treatment failure with other drug therapies. This is a medically accepted indication for the use of Arikayce nebulizer solution outlined in the Medicare approved compendia. However, the plans requirement that there must be confirmation that Arikayce will be used in conjunction with a background multidrug regimen was not satisfied upon initial review.The prescriber has now submitted a letter of medical necessity dated August 17, 2021, that confirms the enrollee will be using Arikayce along with Azithromycin and Rifampin. Therefore, the newly submitted documentation verifies that Arikayce will be used in conjunction with a background multidrug regimen and the plans prior authorization requirement has been met. The plans additional requirements for coverage have also been met, as the record shows the drug is being prescribed for a medically accepted indication; the enrollee is greater than 18 years of age; and the drug is being prescribed by an infectious diseases physician. The Part D plan has no step therapy or quantity limit requirements for this drug. As such, coverage for the drug can be allowed. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a prior authorization request for Tenivac 2-Lf unit/0.5-milliliter-5-Lf unit/0.5-milliliter vaccination. 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 to support the vaccination at issue was a routine booster and was not related to an injury or illness. The plans prior authorization coverage criteria has been met.A physician reviewed the appeal and determined that the requested biologic is eligible for coverage.
Appeal type: Prescription Drug
Decision: Favorable

You asked for reimbursement for Prednisolone Acetate 1 percent eye drops. 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 enrollee has submitted the receipt of purchase for Prednisolone Acetate 1 percent eye drops which are on the plans formulary. The documentation indicates the eye drops are for cataract surgery purposes and this is supported as an approved use per Medicare approved compendia. A physician reviewed your appeal and determined that the plan is required to cover reimbursement of Prednisolone Acetate 1 percent eye drops.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Transdermal Scopolamine 1.5-milligram Patch Biweekly applied during Part A electroconvulsive therapy sessions. The case was auto-forwarded by the plan. The requested drug is not on the plans formulary. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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.Based on the information provided, we determined the drug may be eligible for coverage under Part B under Medicare rules.   As such, the plan is not required to reimburse you for the cost of the Transdermal Scopolamine 1.5-milligram Patches Biweekly.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 Lenvatinib 20-milligram capsules to treat metastatic melanoma. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. Medicare-approved compendia do not contain any citations to support the use of the requested drug as prescribed, for treatment of the noted diagnosis. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.  As such, an exception request, based on medical necessity, cannot be considered because the drug as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the drug is not eligible for coverage under Medicare Part D for the noted diagnosis.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 Amlodipine compounded capsule prescribed to treat the diagnosis of hypertension. The Part D plan denied the appeal 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 record shows Amlodipine compounded capsule was prescribed. This requested compound drug contains bulk powder ingredients. Drugs compounded from bulk powders are not United States Food and Drug Administration approved. We determined the plan is not required to cover the requested drug because it is excluded from coverage under Part D. 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 coverage of Dronabinol 5-milligram capsules, 90 capsules per 30 days. The Part D plan denied the request for coverage because the amount prescribed exceeded the plans quantity limit. Additionally, 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 prescriber has indicated that Dronabinol was prescribed for cyclic vomiting syndrome and multiple other medical conditions including chronic low back pain, opioid use disorder, depression, cervical disc disorder, hypertension, diabetes, lower limb edema, and widespread arthritis. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted conditions. Therefore, the drug is being prescribed for non-medically accepted indications and is not eligible for coverage under Medicare Part D. Since the drug is not eligible for coverage under Medicare Part D, the plans quantity limit for the drug is not relevant 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 Piqray 300 milligrams prescribed daily to treat metastatic colorectal cancer with PIK3CA mutation. 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 Piqray was prescribed to treat metastatic colorectal cancer with PIK3CA mutation. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.  As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug.  A physician reviewed your appeal and determined that the plan is not required to cover Piqray.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Desvenlafaxine Succinate ER 25 milligram tablets prescribed as directed for general anxiety disorder in an adult. 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 your doctor prescribed Desvenlafaxine Succinate to treat your general anxiety disorder. However, the Medicare approved compendia do not support the use of this drug for your condition.  Of note the prescriber changed the diagnosis and stated in the reconsideration appeal that the drug was being used to treat 'Depressive episode, unspecified.'  Medical records were requested.  No medical records were provided.  A physician reviewed your appeal and determined that the plan is not required to cover Desvenlafaxine Succinate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch to treat polyneuropathy. 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 Lidocaine 5% patch was prescribed to treat polyneuropathy. However, the Medicare approved compendia do not support the use of this drug for the enrollee's condition. A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for Mucinex ER 600 milligram tablet. 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 reviewed your appeal carefully. We reviewed all documentation available. Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.We determined that the plan is not required to cover Mucinex ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Dronabinol 5-milligram capsules. 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 Dronabinol was prescribed because the enrollee is underweight. 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 Butrans 5 microgram/hour patch prescribed for severe 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 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 prior authorization questionnaire and medical records support that the enrollee has not been receiving an extended release opioid for at least 30 days and the enrollee has not been taking an immediate release opioid for at least one week. The 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 Butrans.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Rivastigamine 4.6-milligram Transdermal Patch 24 Hour to treat the enrollees condition.   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.Rivastigamine 4.6-milligram Transdermal Patch is a generic drug on Tier 4 pf the plans formulary. There are no drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.  Our physician reviewer's opinion is that tiering exception criteria are not met.