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

At issue is coverage for Ivermectin 3 milligram tablet to treat intestinal strongyloidiasis. 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 reviewed all available documentation. The Part D plan is responsible for determining whether the requested drug has been prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition is a medically accepted indication for the drug as outlined in the Medicare approved compendium, Prescriber statement and records with current laboratory data which confirm diagnosis. Therefore, the drug is being prescribed for a medically accepted indication.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 coverage for Lybalvi 20-10 milligram tablet to treat schizoaffective disorder. 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 reviewed all available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition 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 drug is being prescribed for a non-medically accepted indication.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 coverage for Forteo 600 microgram per 2.4 milliliter injection pen to treat age related osteoporosis without current pathological fracture. 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 reviewed all available documentation. The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. Furthermore, the documentation does not support the medical necessity for an exception to the plans prior authorization requirements. 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 coverage for Riluzole 50 milligram tablet to treat bipolar disorder, unspecified. 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 reviewed all available documentation. The use of the requested drug to treat the noted condition 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 drug is being prescribed for a non-medically accepted indication.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 coverage for Voriconazole 200 milligram tablet to treat cerebral cryptococcosis, cryptococcal meningitis. 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 reviewed all available documentation. The Part D plan is responsible for determining whether the requested drug has been prescribed for a medically accepted indication outlined in the Medicare approved compendia. The noted conditions are off-label uses for the requested drug. 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 drug is being prescribed for non-medically accepted indications. 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 coverage for Doptelet 20 milligram tablet to treat thrombocytopenia secondary to chemotherapy. 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 reviewed all available documentation. The use of the requested drug to treat the noted condition 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 drug is being prescribed for a non-medically accepted indication. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: At-Risk Determination
Decision: Unfavorable

Medicare rules require that if a Part D sponsor affirms an at-risk determination on appeal, the case must be automatically forwarded to the Part D Independent Review Entity (IRE) for review and resolution. The plan forwarded this case to us as required by Medicare rules.This letter is about our decision on the enrollees appeal to Humana Inc. The enrollee asked Humana Inc. to cover Methadone 10 milligram tablets.We received an auto-forwarded reconsideration request from the plan to review the at-risk determination. The plan imposed a 90-morphine milligram equivalent (MME) restriction/limitation per day effective April 20, 2023.We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation shows the enrollees daily MME for Methadone alone was 320. Therefore, the plan determined a safety edit is necessary and the enrollee has been placed in the Part D plans Drug Management Program (DMP) as of April 20, 2023.A physician determined the plans restriction/limitation, through a DMP, is appropriate as there is a risk of obtaining an unsafe quantity of frequently abused drugs (i.e., opioids and benzodiazepines).
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Hyoscyamine Sulfate 0.125 milligram sublingual tablet. 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 reviewed all available documentation.Hyoscyamine Sulfate 0.125 milligram sublingual tablet has not been found by the Food and Drug Administration (FDA) to be safe and effective, and the drug product labeling has not been approved by the FDA. Drugs that are not FDA-approved do not meet the definition of a Part D drug and are excluded from Part D coverage. Therefore, the requested drug is excluded from Medicare Part D coverage.This decision does not address the medical necessity of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Favorable

At issue is coverage for Verquvo 2.5 milligram tablet, 1 tablet daily, to treat symptomatic chronic congestive heart failure with ejection fraction of 15 to 20 percent and a recent hospitalization for heart failure. The Part D plan denied the request for coverage because the drug was not on the plans formulary and the enrollee had not tried the formulary alternative drugs, Jardiance and/or Farxiga.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The requested drug is not on the plans formulary. To grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed or must be deemed contraindicated. In this case, the prescriber has provided patient-specific clinical rationale as to why the alternative drugs on the plans formulary to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Specifically, Jardiance or Farxiga would be contraindicated for this enrollee, as the enrollee is at risk for hypovolemia due to the presence of congestive heart failure and concomitant use of diuretics. Therefore, a formulary exception is supported in this case.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 coverage for Horizant Extended Release 600 milligram tablet to treat chronic low back pain, spinal stenosis of lumbar region. 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 reviewed all available documentation. The use of the requested drug to treat the noted condition 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 drug is being prescribed for a non-medically accepted indication. Of note, formulary exception is not addressed as drug has not been approved.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 Timolol Maleate Preservative Free 0.5 percent ophthalmic solution prescribed for primary open angle glaucoma. 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. 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, Akorn Incorporated, 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 the Timolol Maleate. 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 coverage for Ibsrela 50 milligram tablet to treat constipation, unspecified. 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 reviewed all available documentation. The use of the requested drug to treat the noted condition 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 drug is being prescribed for a non-medically accepted indication. Of note, formulary exception is not addressed as drug has not been approved.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 coverage for Megestrol Acetate 625 milligram per 5 milliliter oral suspension to treat persistent idiopathic weight loss, geriatric cachexia. 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 reviewed all available documentation.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The noted conditions are off-label uses for the requested drug. 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 drug is being prescribed for non-medically accepted indications.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 Beclomethasone Dipropionate Powder 5 milligram per 5 milliliter in capsule form prescribed to treat graft versus host disease of the mouth. 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 the case file from the plan, and any information submitted at the reconsideration level.Drugs that fall into the category of bulk powders do not meet the definition of a Part D drug. The requested drug is considered a bulk powder/ or is consistent of bulk powder ingredients and is excluded from coverage under Part 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 coverage for Ambisome for suspension 25 milligram to treat pulmonary aspergillosis in an enrollee with cystic fibrosis. 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 reviewed all available documentation.The documentation indicates that the requested drug is going to be used with a nebulizer in the enrollees home or home-like setting. Medicare classifies nebulizers as durable medical equipment. Medicare rules state that Medicare Part B pays for the rental and purchase of durable medical equipment. Additionally, payment will be made under Medicare Part B for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals, which must be put directly into the equipment. Any drug available for coverage under Medicare Part B cannot be covered under Part D, per Medicare rules. Therefore, the requested drug is not eligible for Medicare Part D coverage.This decision does not address the medical necessity of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit. Please submit the request for coverage through Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Ozempic 0.25 milligram or 0.5 milligram solution pen injector to treat body mass index 50.0-59.9, adult and impaired fasting glucose. The Part D plan auto-forwarded the case to us for review. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.Drugs prescribed to treat loss of appetite (anorexia) and/or weight loss that is not related to acquired immune deficiency syndrome (AIDS) wasting or cachexia due to chronic disease are excluded from the Part D coverage. Therefore, the requested drug is excluded from Medicare Part D coverage. This decision does not address the medical necessity 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 coverage for Ibsrela 50 milligram tablet to treat chronic idiopathic constipation. 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 reviewed all available documentation. The use of the requested drug to treat the noted condition 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 drug is being prescribed for a non-medically accepted indication. Of note, formulary exception is not addressed as drug has not been approved.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 coverage for Tadalafil 5 milligram tablet daily. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support a covered diagnosis and that all formulary alternatives were tried and failed or were deemed contraindicated. However, the prescriber did not respond to our request.The Part D plan is responsible for determining whether the requested drug has been prescribed for a medically accepted indication outlined in the Medicare approved compendia. The submitted documentation does not include medical records or evidence of a prescribed diagnosis. This information was requested by the Part D plan with no response from the prescriber/prescribers office. The documentation submitted at reconsideration also does not include medical records or evidence of a prescribed diagnosis. As such, there is insufficient documentation available to establish that the requested drug has been prescribed for a medically accepted indication.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 coverage for Insulin Lispro 100 units per milliliter solution to treat type 1 diabetes mellitus. 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 reviewed all available documentation. During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support that all formulary alternatives were tried and failed or were deemed contraindicated. However, the prescriber did not respond to our request.The submitted documentation indicates that the requested drug is being administered via a home infusion pump. Medicare classifies home infusion pumps as durable medical equipment. Medicare rules state that Medicare Part B pays for the rental and purchase of durable medical equipment. Additionally, payment will be made under Medicare Part B for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals, which must be put directly into the equipment. Any drug available for coverage under Medicare Part B cannot be covered under Part D, per Medicare rules. Therefore, the requested drug is not eligible for Medicare Part D coverage.This decision does not address the medical necessity of the item. It only establishes that payment cannot be made under the Medicare Part D benefit. Please submit the request for coverage through Medicare Part B.
Appeal type: At-Risk Determination
Decision: Unfavorable

At issue is Fentanyl 12 microgram per hour 72 hour patch to treat severe arthritis pain in spine, hands, and feet and opioid dependence, uncomplicated. The Part D plan denied the request for coverage and then auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to clarify the diagnosis and to support that the medication is medically necessary and appropriate for the enrollee. However, the prescriber did not respond to our request.The record shows the plan has an opioid restriction in place for the enrollee effective April 13, 2023. The documentation does not show the enrollee should be exempt due to cancer, hospice status, or end-of-life-care. In addition, the documentation does not have a prescribers statement that validates the opioid medication is medically necessary and safe for the enrollee. Therefore, the drug is not eligible for Part D coverage.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: At-Risk Determination
Decision: Unfavorable

At issue is Oxycodone/Acetaminophen 10/325 milligram tablet to treat severe arthritis pain in spine, hands, and feet and opioid dependence, uncomplicated. The Part D plan denied the request for coverage and then auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation. During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to clarify the diagnosis and to support that the medication is medically necessary and appropriate for the enrollee. However, the prescriber did not respond to our request.The record shows the plan has an opioid restriction in place for the enrollee effective April 13, 2023. The documentation does not show the enrollee should be exempt due to cancer, hospice status, or end-of-life-care. In addition, the documentation does not have a prescribers statement that validates the opioid medication is medically necessary and safe for the enrollee. Therefore, the drug is not eligible for Part D coverage.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 coverage for Xyosted 100 milligram per 0.5 milliliter auto-injector to treat abnormal level of hormones in specimens from male genital organs. The Part D plan denied and auto-forwarded the case to us for review. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to clarify the diagnosis and to confirm that all formulary alternatives were tried and failed or were deemed contraindicated. However, the prescriber did not respond to our request.The use of the requested drug to treat the noted condition 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 drug is being prescribed for a non-medically accepted indication.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is coverage for Prolia 60 milligram per milliliter injector to treat age-related osteoporosis without current pathological fracture . 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 reviewed all available documentation.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation supports that all of the plans requirements for coverage have been satisfied. Specifically, the documentation supports the enrollee has a total spine T-score of minus 2.9. Therefore, the plans prior authorization requirements have been met and coverage for the drug is supported.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.