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

At issue is coverage for Pretomanid 200 milligram tablet, 30 tablets per 30 days. The Part D plan denied the request for coverage because the documentation did not confirm the drug was going to be used in combination with Bedaquiline and Linezolid. As such, 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 reviewed all documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.The submitted medical records and prescriber statement confirm that the requested drug will be given in combination with Bedaquiline and Linezolid for the treatment of pulmonary multidrug-resistant tuberculosis. This drug combination of Pretomanid, Bedaquiline and Linezolid for the treatment of pulmonary multidrug-resistant tuberculosis is a medically accepted indication for the drug as outlined in the Medicare approved compendia and the Food and Drug Administration (FDA) product label. Therefore, the drug is being prescribed for a medically accepted indication. However, the requested drug is not on the plans formulary. It is noted that the enrollee has already been treated with numerous tuberculosis drugs and has had adverse reactions to some previous medications. The documentation indicates that the enrollee already completed treatment with Rifapentine, Isoniazid, Pyrazinamide, and Ethambutol (RIPE) therapy. In addition, the medical records show that the enrollee also previously tried Levofloxacin arid Rifabutin, which had to be discontinued due to negative side effects of abdominal pain, nausea, and emesis. Finally, the records show that the enrollee is currently taking the antibiotic, Cefdinir. Given that the submitted documentation confirms the requested drug is being prescribed for a medically accepted indication and the medical records show that the enrollee has completed previous drug treatment regimens to treat the tuberculosis and has tried and failed other antibiotics for this condition, 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 Latuda 20 milligram tablets to treat anxiety disorder and intermittent explosive disorder. 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, including 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 diagnosis. 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 Testosterone 1 percent gel. The Part D plan denied the request.We received the submitted documentation to perform an independent and de novo review.The submitted documentation does not include medical records or evidence of a prescribed diagnosis. Therefore, it cannot be determined if the drug was 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 Sulfasalazine 500 milligram tablets to treat rheumatoid arthritis. 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, including the case file from the plan, and any information submitted at the reconsideration level.The requested 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. In this case, the documentation does not support why the formulary alternatives, required by the plan would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm.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 Auryxia 210 milligram tablets to treat hyperphosphatemia in end-stage renal disease. 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, including the case file from the plan, and any information submitted at the reconsideration level.The requested 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. In this case, the documentation does not support why the formulary alternatives, required by the plan would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm.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 Ursodiol 300 milligram capsules to treat primary biliary cholangitis. 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, including 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 in capsule form, for the treatment of this diagnosis. 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 a tiering exception request for Eliquis 5 milligram tablets as anti-coagulation therapy for the prophylaxis of emboli. 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, including 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 tiers of the plans formulary to treat the same diagnosis. Therefore, this drug is not eligible for a tiering exception.A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanz 5 milligram tablets to treat planopilaris and alopecia. 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, including 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 diagnosis. Therefore, the requested drug is not eligible for coverage under Medicare Part D. Of note, the request for a quantity limit exception cannot be allowed as the drug at issue has not been approved for 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 Latuda 40 milligram tablet. The Part D plan denied the request for coverage. Additionally, the Part D plan denied a tiering exception request for the drug.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.The prescriber has indicated that the requested drug has been prescribed for the treatment major depressive disorder with psychotic features and anxiety disorder. However, 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 and is not eligible for coverage under the Medicare Part D plan. Since the drug is not eligible for coverage by the plan, a tiering exception is not relevant.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 tiering exception request for Jardiance 10 milligram tablets to treat the enrollee's condition. 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, including 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 brand drugs of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this drug is not eligible for a tiering exception.A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Lynparza 100 milligram tablet to treat advanced eccrine porocarcinoma with BARD mutation. 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 documentation submitted, including the case file from the plan and any information submitted at the reconsideration level. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. The prescriber did not submit any clinically relevant, peer-reviewed journal articles from a Medicare approved journal to support this appeal. As such, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.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 Xeljanz 5 milligram tablets to treat alopecia universalis. 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, including 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 diagnosis. 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 coverage for Trulicity 1.5 milligram per 0.5 milliliter subcutaneous auto injection pen to treat morbid obesity and impaired fasting glucose. 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 documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.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 either 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 Rivastigmine 9.5 milligram per 24 hour patch to treat Alzherimer's dementia. 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, including the case file from the plan, and any information submitted at the reconsideration level.The requested 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. In this case, the documentation does not support why the formulary alternatives, required by the plan would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm.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 Dronabinol 2.5 milligram capsules. 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, including 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.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 Dupixent 300 milligram per 2 milliliter pen injection to treat atopic dermatitis. 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, including the case file from the plan, and any information submitted at the reconsideration level.The requested 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. In this case, the documentation does not support why the formulary alternatives, required by the plan would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm.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 Modafinil 200 milligram tablets to treat opioid-induced sleep disorder. 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, including 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 diagnosis. 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 Vtama 1 percent cream. The Part D plan denied the request as an excluded drug in the Medicare Part D program.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.For the drug at issue to be covered under Medicare Part D, the manufacturer must participate in the Medicare Coverage Gap Discount Program. This manufacturer is not participating in the program; therefore, the drug is excluded from Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Zolpidem Tartrate ER 12.5 milligram extended-release tablet to treat insomnia and tinnitus. 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 documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.The use of the requested drug to treat the tinnitus is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug for the treatment of this tinnitus. Therefore, the drug is being prescribed for a non-medically accepted indication for the diagnosis of tinnitus.While the use of Zolpidem Tartrate ER to treat insomnia is a medically accepted indication for the drug outlined in the Medicare approved compendia, the plan has prior authorization requirements for this drug that must be met before coverage can be approved. The submitted documentation does not support that all of the plans requirements for coverage have been met.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 Humira 40 milligram per 0.8 milliliter injection solution to treat anterior uveitis. 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, including the case file from the plan, and any information submitted at the reconsideration level.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans 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: Unfavorable

At issue is a tiering exception request for Prolia 60 milligram per milliliter injection solution to treat age-related osteoporosis. 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, including the case file from the plan, and any information submitted at the reconsideration level.Prolia is a biologic  on Tier 4 of the plans formulary. There are no biologics of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this biologic is not eligible for a tiering exception.A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Entresto 24-26 milligram tablet to treat chronic heart failure. 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 documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.The plan has prior authorization requirements for this drug that must be met before coverage can be approved. The submitted documentation does not support that all of the plans requirements for coverage have been met.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 Strensiq 80 milligram per 0.8 milliliter solution to treat hyperphosphatasia. 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, including the case file from the plan, and any information submitted at the reconsideration level.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans 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: Unfavorable

At issue is Repatha Sureclick 140 milligram per milliliter injection solution to treat hyperlipidemia. 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, including the case file from the plan, and any information submitted at the reconsideration level.The requested 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. In this case, the documentation does not support why the formulary alternatives, required by the plan would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm.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 Calcitriol 0.25-microgram capsule prescribed for secondary hyperparathyroidism associated with end stage renal disease with patient currently on dialysis. 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, including the case file from the plan, and any information submitted at the reconsideration level. According to Medicare rules, the requested drug is eligible for coverage under the Part B end stage renal disease payment bundle. Drugs which are eligible for Part B coverage are excluded from Part D coverage. 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 tiering exception request for Repatha SureClick 140 milligram per milliliter solution to treat hyperlipidemia. 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, including the case file from the plan, and any information submitted at the reconsideration level.Repatha SureClick 140 milligram per milliliter solution is a biologic on Tier 3 of the plans formulary. There are no biologics of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this biologic is not eligible for a tiering exception.A physician reviewer determined that the tiering exception criteria are not met.