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

At issue is Rytary 48.75 milligram capsules prescribed for parkinsonism tremors. 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.Rytary is a brand drug on Tier 4 of the plans formulary. There are no other 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 Symbicort 160-4.5 microgram inhaler. 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. Symbicort 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 Mycophenolate Sodium DR 360 milligram tablet prescribed twice daily 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.The record shows the enrollee had a kidney transplant on April 13, 2001. 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 Mycophenolate Sodium DR 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 Mycophenolate Sodium DR. 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 Gammaplex 10% vial prescribed for use with an infusion pump for the treatment of chronic inflammatory demyelinating 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 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 Gammaplex 10% is being administered to the enrollee via external infusion pump that is used in the home. According to Medicare rules, Medicare Part B pays for the rental and purchase of durable medical equipment if the equipment is used in the patients home. Payment may be made for supplies necessary for the effective use of DME, including drugs and biologicals, which must be put directly into the equipment to achieve the therapeutic benefit of the durable medical equipment. We determined that the Medicare Part D plan is not required to cover Gammaplex 10%. 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. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Uro-MP 118-10-40.8-36-0.12 milligram capsules to treat an unknown condition. 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 appeal request is for Uro-MP 118-10-40.8-36-0.12 milligram capsules. However, the requested drug 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. Therefore, the requested drug is excluded from coverage. 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 Ipratropium Bromide-Albuterol Sulfate 0.5/2.5 (3) milligrams/3 milliliter nebulizer solution prescribed for cough. 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 a quantity limit exception for Doxazosin Mesylate 2-milligram tablets (270 tablets/90 days) prescribed for hypertension. 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 documentation indicates the prescriber ordered the requested drug for the enrollees noted condition. The prescriber ordered a quantity of 270 tablets per 90 days. The plan has a quantity limit restriction of one tablet per day on the requested drug. The submitted documentation does not indicate that a higher strength dosage of the same medication would be ineffective in treating the enrollees condition. Therefore, a quantity limit exception cannot be granted and the amount approved by the plan is upheld.The plan is not required to cover the requested drug for a quantity limit exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vumerity Delayed Release 231 milligram capsule prescribed for multiple 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 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 prescriber indicates Vumerity Delayed Release capsule is prescribed for multiple sclerosis. However, the drug is not on the plans formulary. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. We requested additional information from the prescriber but did not receive a response. In this case, the prescriber does not indicate as to why the other alternative on the plans formulary would not work.A physician reviewed your appeal and determined that the plan is not required to cover Vumerity Delayed Release capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Daytrana 10 milligram per 9-hour patch prescribed to treat the enrollee with idiopathic hypersomnia. 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 your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows the doctor prescribed Daytrana 10 milligram per 9-hour patch to treat idiopathic hypersomnia. However, 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 plan is not required to cover Daytrana 10 milligram per 9-hour patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Abirateron Acetate 250 milligram tablets prescribed for metastatic prostate cancer. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We determined that the plan is not required to cover Abirateron Acetate because the drug was part of a clinical trial by a non-Medicare qualified agency/sponsor. Drugs administered as part of a non-qualifying clinical trial are excluded from coverage. 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 Xospata 40-milligram tablets prescribed for acute myeloid leukemia as first line treatment. 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 the drug at issue for the enrollees noted condition. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. There are no Medicare-approved peer-reviewed journal articles to support the use of the drug as first line treatment 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 a formulary exception request for Vemlidy 25 milligram tablets prescribed to treat the enrollee with chronic hepatitis B. 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.Vemlidy 25 milligram tablets is not included in the plans formulary (list of covered drugs). 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 prescriber has not provided patient specific clinical rationale, supported by medical records, as to why 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.A physician reviewed the appeal and determined that the plan is not required to cover Vemlidy 25 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nulojix 250-milligram powder solution prescribed for prophylaxis of acute organ rejection of transplanted lung with seropositive Epstein-Barr virus. 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 the biologic at issue for the enrollees noted condition. The Medicare approved compendia do not support the use of the biologic at issue for the enrollees condition. As the biologic 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 biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycontin CR 15-milligram tablets prescribed for chronic pain. 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.This drug is provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are 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 formulary exception request for Repatha 140-milligram/milliliter injection solution prescribed for atherosclerotic heart disease of native coronary artery and mixed hyperlipidemia. 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 did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed the appeal and determined that the plan is not required to cover Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ipratropium Bromide-Albuterol Sulfate 0.5/2.5 (3) milligrams/3 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

You requested Tobramycin 300 milligram/ 5-milliliter nebulizer solution prescribed as directed for methicillin resistant staph infection unspecified site. 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 Tobramycin to treat your methicillin resistant staph infection unspecified site. 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 Tobramycin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Promethazine HCL 25 milligram tablet prescribed for nausea and vomiting. 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. We asked the prescriber to send us information regarding the enrollee's condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. We did not receive the documentation requested.. The documentation shows Promethazine HCL 25 milligram tablet was prescribed to treat nausea and vomiting. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Promethazine HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dexmethylphenidate Hydrochloride ER 5 milligram capsules prescribed as directed for narcolepsy without cataplexy. 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. Your medical records show your doctor prescribed Dexmethylphenidate Hydrochloride ER to treat your narcolepsy without cataplexy. However, the record does not include information to support the reason your physician prescribed the drug above the quantity limit. An exception to the quantity limit criteria was not met. Therefore, the plan is not required to cover the requested quantity of Dexmethylphenidate Hydrochloride ER.A physician reviewed your appeal and determined that the plan is not required to cover the Dexmethylphenidate Hydrochloride ER, 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 Humira CF 80-milligram/0.8 milliliter pen injector prescribed for ulcerated and chronic necrobiosis lipoidica diabeticorum. 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 the biologic at issue for the enrollees noted condition. The Medicare approved compendia do not support the use of the biologic at issue for the enrollees condition. As the biologic 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 biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram tablets 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.Eliquis 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 a request for reimbursement of $18.89 paid on June 18, 2021, for Rosuvastatin 10 milligram tablets.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. The drug Rosuvastatin is on Tier 1 of the Part D plans formulary. Drugs included on Tier 1 of the formulary have a $24.00 copy when a 90-day prescription is filled at a standard retail in-network pharmacy. If the cost of the drug is less than the copay, then the enrollee will be charged the lower cost. The records show that the enrollee filled a 90-day prescription for the Rosuvastatin 10 milligram tablets on June 18, 2021, at Costco Pharmacy, for $18.89. The enrollee was correctly charged the lower cost of $18.89, instead of the $24.00 copay. Therefore, the plan is not required to provide any reimbursement for the Rosuvastatin 10 milligram tablets that were purchased on June 18, 2021.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Diovan 320 milligram tablets prescribed for hypertension. 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 information from the prescriber. Specifically, we requested medical records and a prescriber statement to support all formulary alternatives were tried and failed. However, we did not receive the requested information.The submitted documentation did not indicate that all the formulary alternatives were tried and would be ineffective.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 Sildenafil Citrate 20 milligram tablets, 60 tablets per 12 days. The Part D plan denied the request because the plans prior authorization requirements were not met. Additionally, the amount requested exceeded the plans quantity limit of 90 tablets per 30-day supply.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 Sildenafil Citrate has been prescribed for the treatment of testicular hypofunction. However, the Medicare approved compendia do not contain any citations to support the use of 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. Since the drug is not eligible for coverage, the plans prior authorization and quantity limit requirements are not relevant to this review. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.