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

At issue is Prolia 60 milligram/milliliter prefilled syringe to treat osteoporosis. 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 provided addressed the plans coverage criteria, and those criteria were not satisfied. 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 a formulary exception request for coverage of Oxervate 0.002 percent eye drops, 14 milliliters per 60 days, prescribed for the treatment of neurotrophic keratitis. The Part D plan approved coverage for the drug. However, the plan denied the request for a 60-day supply.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. Oxervate 0.002 percent eye drops are a specialty drug. Specialty drugs are limited to a recurring 30-day supply by the plan. An exception to this quantity limit requirement will not be granted by the plan. A physician reviewed the appeal and determined that the plan is not required to cover more than a recurring 30-day supply of the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Nurtec ODT 75-milligram tablets prescribed for migraine, unspecified, not intractable, without status migrainosus. 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 Nurtec ODT.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amphetamine-Dextroamphetamine 30 milligram tablets prescribed for attention-deficit hyperactivity disorder, combined type. 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 submitted shows the prescriber ordered Amphetamine-Dextroamphetamine to treat the enrollees condition of attention-deficit hyperactivity disorder, combined type. However, the Medicare approved compendia do not support the use of this drug with dosing that exceeds 60 milligrams per day.A physician reviewed the appeal and determined that the plan is not required to cover Amphetamine-Dextroamphetamine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methylphenidate Hydrochloride 5-milligram tablets prescribed for traumatic brain injury. 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. 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: Favorable

At issue is Forteo 620-microgram/2.48-milliliter pen injector prescribed for osteoporosis with current pathological fracture. 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 the enrollee has met the plans prior authorization coverage criteria. We received the requested information and included it in the review. The submitted documentation indicates the biologic at issue was prescribed for the enrollees noted condition. The Medicare approved compendia support the use of the biologic for the noted condition. Furthermore, the prescriber submitted a prescriber statement to support the enrollee has met the plans prior authorization coverage criteria. The submitted documentation supports the enrollee has a history of vertebral fracture, a history of a fragility fracture within the past five years, has a T-score of -4.2, and has failed a biophosphonate. The plans prior authorization criteria have been met. A physician reviewed your appeal and determined that the plan is required to cover the requested biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Rosuvastatin Calcium 20 milligram tablets, 135 tablets per 90 days, prescribed for the treatment of hyperlipidemia. 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. The plan has prior authorization requirements for coverage of this drug, which include step therapy and quantity limit requirements. The amount requested exceeds the plans quantity limit for Rosuvastatin Calcium 20 milligram tablets, which is 30 tablets per 30 days, or 90 tablets per 90 days. Additionally, the plan has a step therapy requirement that has not been addressed by the prescriber. During this review, a request was submitted to the prescriber to address the plans quantity limit and step therapy requirements. A reply from the prescriber was not received. Therefore, an exception to the quantity limit and step therapy criteria is not supported. 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 Jardiance 10-milligram tablets prescribed for type II diabetes mellitus. 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.Jardiance is a brand drug on Tier 3 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 a request for coverage of Budesonide EC 3 milligram capsules to be given once daily to treat ulcerative colitis. The Part D plan denied the request for coverage because the approved Medicare compendia only supported the use of Budesonide 9-milligram extended-release tablets for treatment of ulcerative colitis.  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 noted at reconsideration that the enrollee requires Budesonide to treat collagenous colitis, which is a type of microscopic colitis. The documentation submitted at reconsideration also includes a pathology report from the enrollees recent colonoscopy that confirms a diagnosis of collagenous colitis. The approved Medicare compendium, DrugDex, does include a citation for the use of oral Budesonide in the treatment of microscopic colitis. However, the dosage guidelines outlined in DrugDex for oral Budesonide in the initial treatment of microscopic colitis is 9-milligrams daily for 8 weeks and for maintenance therapy is 6-milligrams daily over 6 months or 3-milligrams daily alternating with 6-milligrams daily over 12 months to be tapered to lowest effective dose. Since the documentation supports that the drug is being requested for initial therapy, the Budesonide at the requested dose is not supported by the approved Medicare compendia. As such, the 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 the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycappsa DR 20 milligram capsule prescribed for acromegaly. 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 prescriber has provided patient specific clinical rationale and medical records. However, the documentation does not address 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 a request for coverage of Dronabinol 10-milligram capsules, 90 capsules per 30 days, prescribed for the treatment of chemotherapy-induced nausea and vomiting for an enrollee who has metastatic colon cancer. The Part D plan denied the request because the amount requested exceeded the plans quantity limit. Additionally, coverage for the drug would be available under Medicare Part B. 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 Dronabinol is being used for chemotherapy-induced nausea and vomiting within 48 hours of chemotherapy administration. Drugs used to treat nausea and vomiting within 48 hours of cancer chemotherapy are eligible for coverage under Medicare Part B. Drugs that are eligible for Part B coverage are excluded from Part D coverage by Medicare law. As such, the decision is that the Part D plan is not required to cover the requested drug. Since the Part D plan is not required to cover the drug, the plans quantity limit requirements are not relevant to this review. 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 Orencia 250 milligram solution prescribed for rheumatoid arthritis. 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.Drugs furnished Incident To a physicians service are excluded from Medicare Part D coverage.  Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Vascepa 1-gram capsule prescribed for 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. 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 Vascepa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Rinvoq 15-milligram extended release tablets prescribed for rheumatoid arthritis. 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 Rinvoq.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5-percent patch prescribed for unspecified hip osteoarthritis pain. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We requested additional documentation from the prescriber. Specifically, we requested medical records and a prescriber statement. However, we did not receive the requested information.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. 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 Xeljanz XR 11-milligram tablets prescribed for refractory amyopathic dermatomyositis. 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. 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 Viibryd 20-milligram tablets. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We requested additional information from the prescriber. Specifically, we requested medical records to support a covered diagnosis and a prescriber statement to support the enrollee satisfies the plan's prior authorization coverage criteria. However, we did not receive the requested information.The submitted documentation does not include medical records or evidence of a prescribed diagnosis. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Scopolamine 1-milligram 72-hour patch prescribed for motion sickness. 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. We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the enrollee satisfies the plan's prior authorization coverage criteria. However, we did not receive the requested information.The submitted documentation does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.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 Procrit solution 10,000 unit/milliliter solution to treat chronic kidney 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 plan requires for coverage of Procrit that the enrollee have anemia due to chronic kidney disease, not on dialysis and a current hemoglobin level of less than 12 grams deciliter. The documentation includes clinical notes which satisfied the plan's coverage criteria. 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 a formulary exception request for Aubagio 14-milligram tablets prescribed for relapsing-remitting multiple sclerosis. 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 Aubagio.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine HCL 8 milligram sublingual tablet to treat trigeminal neuralgia. 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 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, Buprenorphine HCL is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Lortab 10-milligram-300 milligram/15-milliliter oral solution prescribed for chronic cancer pain. 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 Lortab.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550-milligram tablets prescribed for hepatic encephalopathy. 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 included on Tier 5 of the plans formulary. This tier is identified as a Specialty Tier. The plan is not required to grant a tiering exception for drugs available on their Specialty Tier. Therefore, a tiering exception cannot be considered.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 Armodafinil 150 milligram tablet to treat fatigue secondary to multiple sclerosis. 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 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550-milligram tablets prescribed for other specified diseases of intestine. 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 prescriber ordered Xifaxan to treat the enrollees condition of other specified disease of intestine. 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 Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Corlanor 5-milligram tablets prescribed for chronic systolic heart failure. 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 submitted shows the prescriber ordered Corlanor to treat the enrollees condition of chronic systolic heart failure. However, the Medicare approved compendia do not support the use of this drug for an enrollee with NYHA Class I heart failure who is not in sinus rhythm. A physician reviewed the appeal and determined that the plan is not required to cover Corlanor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliquis 5 milligram tablet. 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.Eliquis is a brand drug on Tier 2 of the plans formulary. There are no brand 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.