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

At issue is Otezla 10 & 20 & 30 milligram therapeutic pack prescribed for lichen planus. 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 Otezla is prescribed for severe recalcitrant, erosive oral lichen planus with nail involvement. However, Medicare approved compendia do not support the use of this drug for this condition.  A physician reviewed your appeal and determined that the plan is not required to cover Otezla.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Taltz 80 milligram/milliliter auto injector prescribed as directed for psoriatic arthritis. 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. 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 medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Taltz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Welchol 6 milligram tablet to treat diarrhea. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. The drug is also not on the plan's formulary.  We received a reconsideration request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat functional diarrhea in an enrollee with a history of cholecystectomy is an off-label use.  Medical records were provided which support this diagnosis. 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, Welchol is not eligible for coverage under Medicare Part D. Since the drug is not eligible for coverage under Part D, the plans formulary exception requirements are not applicable to this review. A physician reviewed the appeal and determined that the plan is not required to cover Welchol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Taltz 80 milligrams per milliliter autoinjector prescribed 160 milligrams week zero; 80 milligrams weeks two, four, six, eight, 10, and 12; and then 80 milligrams every four weeks for plaque psoriasis. 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. 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. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported. A physician reviewed the appeal and determined that the plan is not required to cover Taltz 80 milligrams per milliliter autoinjector.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is teriparatide 20 micrograms per dose, pen injector, prescribed twice daily for resistant hypocalcemia due to hypoparathyroidism. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. 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.Teriparatide has an orphan drug designation per the Micromedex compendia and therefore is considered a medically accepted indication per Medicare guidance. However, the documentation provided addressed the plans coverage criteria and those prior authorization criteria were not satisfied.  A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage. This decision does not speak to the medical necessity of this drug for your condition. This decision speaks to whether your plan is required to provide coverage under Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Silodosin 4-milligram capsules prescribed for the treatment of benign prostatic hyperplasia with lower urinary tract symptoms. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we read 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.Silodosin is not included in the plans formulary (list of covered drugs). The prescriber has not provided sufficient patient specific clinical rationale 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 formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tadalafil 5-milligram tablet 180-tablets/30-days to treat benign prostatic hyperplasia with lower urinary tract symptoms. 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 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.Tadalafil 5-milligram tablet is being provided by the plan under a formulary exception. The plan limits the amount of Tadalafil 5-milligram tablets provided to you as a non-formulary exception to a 30-day supply of 1-tablet per-day. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that quantity limit criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Saxenda 18-milligram per 3-milliliter subcutaneous injection pen prescribed for severe obesity due to excess calories. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any records submitted at the reconsideration level. Any drug used for weight loss (even if used for a non-cosmetic purpose, i.e., morbid obesity) is excluded from the 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 request for reimbursement for autologous ophthalmic 50 percent serum eye drops purchased on March 4, 2021, which have been prescribed for the treatment of severe dry eye disease. The Part D plan denied the request for reimbursement. We received the case to perform an independent and de novo review. To make our decision, we read 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.Autologous serum eye drops have not been approved by the Food and Drug Administration (FDA). Because the drops are a unique blood product, they cannot be mass-produced for FDA approval. Drugs not approved by the FDA are excluded from Part D coverage. Therefore, the Part D plan is not required reimburse payment for the requested drug. This decision does not address the medical necessity or appropriateness of the requested 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 request for Benzonatate 1000 milligram capsule to treat an unknown diagnosis.   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 Medicare approved compendia support the use of Benzonatate for symptomatic relief of cough. Drugs prescribed for the symptomatic treatment of cough and colds are excluded from coverage under Medicare Part D. Therefore, Benzonatate is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Brompheniramine-Pseudoephedrine-Dextromethorphan 2-30-10 milligram/5 milliliter.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. Cough and cold medicines are excluded from Part D drug 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.We determined that the plan is not required to cover Brompheniramine-Pseudoephedrine-Dextromethorphan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tuberculin Syringe prescribed for seropositive Rheumatoid Arthritis with a positive CCP. The Part D plan denied the request.We performed 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. In accordance with 42 CFR, medical supplies including syringes, needles, alcohol swabs, and gauze are not considered Part D drugs and may be covered under the Medicare Part B durable medical equipment benefit.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a prior authorization request for Revlimid 15-milligram capsules prescribed for monoclonal gammopathy of renal significance. 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 met the plans prior authorization coverage criteria. We received additional information and included it in the review.The submitted documentation indicates the prescriber ordered the drug at issue as combination therapy with Dexamethasone and Daratumumab for the enrollees condition. The submitted documentation includes a Category 1 recommendation from the National Comprehensive Cancer Network that indicates the combination therapy identified is the preferred regimen for progressive disease. The enrollee has not exhibited proper response after previous theapy, which classifies the enrollees condition as persistent/progressive disease. The recommendation further indicates the treatment for the enrollees condition follows the guidelines for multiple myeloma. The prior authorization coverage criteria indicates that all compendia approved indications can be approved. Therefore, an exception to the plans prior authorization coverage criteria can be made.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 Vitamin D3 25 microgram tablet.  The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we reviewed the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter (OTC) are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Dexilant DR 60 milligram capsule. 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.Dexilant DR is a brand drug on Tier 4 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Haloperidol Decanoate 50 milligram/milliliter vial prescribed for restlessness, agitation, Alzheimers disease, and pseudobulbar affect. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation indicates Haloperidol Decanoate 50 milligram/milliliter vial is prescribed to treat restlessness, agitation, Alzheimers disease, and pseudobulbar affect. However, Medicare approved compendia do not support the use of this drug for this condition.  A physician reviewed your appeal and determined that the plan is not required to cover Haloperidol Decanoate 50 milligram/milliliter vial.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Dupixent 300-milligram/2-milliliter injection prescribed for severe persistent asthma with eosinophilic phenotype. 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 biologic is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Megestrol Acetate 40 milligram/milliliter suspension prescribed for anorexia in an enrollee with interstitial pulmonary disease, unspecified. 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 documents indicate Megestrol Acetate is prescribed for anorexia in an enrollee with interstitial pulmonary disease, unspecified. However, Medicare approved compendia do not support the use of this drug for this condition.  A physician reviewed your appeal and determined that the plan is not required to cover Megestrol Acetate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Livalo 2-milligram tablets prescribed for pure hypercholesterolemia. 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 Livalo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dronabinol 5-milligram capsule prescribed for chemotherapy-induced nausea and vomiting. 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: Unfavorable

At issue is Udenyca 6 milligrams per 0.6 milliliter. The Part D plan did not make a decision. 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 record shows Udenyca is not covered under Part D. However, this drug is eligible for coverage under Medicare Part B. Medicare law specifically excludes coverage for any drug for which payment would be available under Medicare Parts A or B for that individual. Medicare Part B pays for services and supplies incident to the service of a physician (or other practitioner).We determined that the drug is eligible under Medicare Part B. Therefore, the Part D plan is not required to cover Udenyca. Please consider submitting this request to Medicare Part B. 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 Temazepam 15-milligram capsules prescribed for primary insomnia. 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 records submitted at the reconsideration level. We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. The submitted prescriber statement shows that the prescriber ordered Temazepam to treat the enrollees condition of primary insomnia. The enrollees plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.  Also note that supporting medical records were requested.  No medical records were submitted.A physician reviewed the appeal and determined that the plan is not required to cover Temazepam. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Otezla 30-milligram tablets prescribed for the treatment of plaque psoriasis. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we read 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.Otezla is not included in the plans formulary (list of covered drugs). The prescriber has not provided sufficient patient specific clinical rationale 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 formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Myfortic 360-milligram delayed release tablets prescribed for rejection prophylaxis following a lung transplant. 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 records indicate that the enrollee has been enrolled in Medicare Part A since March 1, 2020, and underwent a Medicare-covered lung transplant on May 15, 2021. Since the patient was enrolled in Medicare Part A during the transplant, the Myfortic would be covered 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. This decision does not refer to the medical necessity of the requested drug. It only establishes that payment cannot be made under the Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Deferasirox 250 milligram tablet for suspension prescribed two tablets daily for chronic iron overload with transfusion-dependent anemia and sickle cell anemia. 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The medical records show the doctor prescribed Deferasirox to treat the enrollees chronic iron overload with transfusion-dependent anemia and sickle cell anemia. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed the appeal and determined that the plan is not required to cover Deferasirox. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.