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

At issue is a formulary exception for Diclofenac Epolamine 1.3% patch prescribed for back 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 does not include medical records or a physician supporting statement. A request for information was sent to the prescriber; however, no further documentation was received. 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 Gemtesa 75 milligram tablets. The Part D plan denied the request for a tiering exception.The QIC 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.Gemtesa is a brand drug on Tier 4 of the plans formulary. The prescriber did not address why the drugs available on the lower tiers of the plans formulary would not work for the enrollee. 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 formulary exception request for Rivastigmine 9.5 milligram/24 hour patch prescribed for unspecified dementia. 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.A request for additional information was made to the prescriber for medical records and a supporting statement. The requested documentation was received.The submitted documentation indicates the prescriber ordered Rivastigmine for unspecified dementia. 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 a request for coverage of Piqray (Alpelisib) 300 milligram tablets, once daily, which has been prescribed for metastatic liposarcoma with PIK3CA mutation. The Part D plan denied the request stating the medication 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 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 medical records indicate that enrollee was diagnosed with metastatic liposarcoma earlier this year and was started on Adriamycin and Dacarbazine. Despite this treatment, the enrollee had progression and was then started on therapy with Gemcitabine and Docetaxel. However, further progression was noted. Molecular profiling was done, which showed PIK3CA mutation.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. However, the record includes an article from the Journal of Clinical Oncology, which is a peer-reviewed, clinically relevant, Medicare-approved journal. The article is titled, Phosphatidylinositol 3 Kinase Alpha Selective Inhibition with Alpelisib in PIK3CA Altered Solid Tumors: Results from the First in Human Study (2019). This study includes patients of all tumor types with the PIK3CA mutation that have been previously treated with several treatments. Although this is a Phase 1 study, the secondary endpoint of the trial was to determine efficacy of the use of Piqray in PIK3CA-mutated solid tumors. The study showed a 60% response rate in some cases. Because this article is from an accepted journal and secondary endpoint of efficacy was achieved, the article will be accepted to support that the Piqray would be a medically acceptable treatment for this enrollee. The plan has no quantity limit or step therapy requirements for Piqray. The plan does have prior authorization requirements for the coverage of this drug. However, these requirements are diagnosis specific and are not relevant to the enrollees diagnosis. Since the article from the Medicare-approved Journal of Clinical Oncology indicates Piqray is an acceptable treatment for the enrollees diagnosis, an exception can be granted to the plans diagnosis-specific prior authorization requirements. A physician reviewed the appeal and determined that the plan is required to cover the Piqray in this case.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Topiramate 100 milligram tablets. 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 indicates that Topiramate has been prescribed for autistic disorder, unspecified mood disorder, and unspecified anxiety disorder. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted conditions. Therefore, the drug is being prescribed for non-medically accepted indications and 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 Dexcom G6 system prescribed for diabetes. 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 item at issue is not directly related to the delivery of insulin. This is eligible for coverage under Part B. The plan does not offer supplemental (additional) coverage for this item. If the enrollee purchased items that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of the item. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregabalin 50 milligram capsules prescribed for low back and right leg 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 indicates the prescriber ordered Pregabalin for low back and right leg pain. 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 Keppra 500 milligram tablets. The Part D plan denied the request for a tiering exception.The QIC 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.Keppra 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: Favorable

At issue is Latuda 20 milligram tablet prescribed for schizoaffective disorder, bipolar 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 records submitted at the reconsideration level. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided shows the enrollee has satisfied the plan's coverage criteria. Specifically, the prescriber has documented that the enrollee has had prior therapy/intolerance to Seroquel and Abilify.  A physician reviewed the appeal and determined that the plan is required to cover Latuda.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acetaminophen-Hydrocodone 300 milligram-5 milligram tablets prescribed for the enrollees condition. 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 Stelara 450 milligram/0.5 milliliter solution prescribed for the enrollees condition. 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 your 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 tiering exception request for Breo Ellipta 100-25 microgram inhalation powder prescribed for moderate persistent asthma. 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. Breo Ellipta is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the enrollees condition on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Farxiga 10 milligram tablet. The Part D plan denied your request for a tiering exception.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 about the enrollee's condition. We also asked for medical records or other documentation to show why the enrollee needs the medication. Specifically, we asked for records to show why similar medications on the lower tiers would not work. However, we did not receive the documentation. Farxiga is a brand drug on Tier 4 of the plans formulary. The prescriber did not address why the drugs available on the lower tiers of your plans formulary would not work for you. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Cyclobenzaprine Hydrochloride ER 15 milligram extended release capsules. The Part D plan denied the request because the drug was being prescribed for a non-medically accepted indication. Additionally, the drug was not included on the plans formulary and the documentation did not support a formulary 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.The submitted medical records indicate that Cyclobenzaprine Hydrochloride ER has been prescribed for muscle spasms related to chronic musculoskeletal conditions. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for 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 under Medicare Part D, a formulary exception is not applicable to this review. 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 Ozempic 0.25-0.5 milligram injector prescribed for the enrollees condition. 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.Ozempic 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 Zolpidem Tartrate 10 milligram tablet prescribed for 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 and other documentation to show why this medication is needed. We did not receive the documentation requested. Specifically, no medical records were provided in the case for review.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 Zolpidem Tartrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Sildenafil 20 milligram tablets. 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 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 has been prescribed for the treatment of unspecified pulmonary hypertension. However, the Medicare approved compendia do not contain any citations to support 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. 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 Buprenorphine Hydrochloride 2 milligram sublingual tablets prescribed for chronic pain syndrome, spondylosis without myelopathy or radiculopathy, lumbar region, and low back 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 indicates the prescriber ordered Buprenorphine Hydrochloride sublingual tablets for chronic pain syndrome, spondylosis without myelopathy or radiculopathy, lumbar region, and low back pain. 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 a request for coverage of Octreotide Acetate 200 microgram per milliliter (0.02 milligram per milliliter) subcutaneous injection solution. The Part D plan denied the request stating that the drug was being used for a non-medically accepted indication. 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 Octreotide Acetate has been prescribed for the treatment of chemotherapy-induced diarrhea. The medical records indicate that the enrollee, who has metastatic pancreatic cancer, was receiving FOLFIRINOX, which is a regimen of chemotherapy agents (5-Fluorouracil, Leucovorin, Irinotecan, and Oxaliplatin) used to treated pancreatic cancer. It is noted in the medical records that the enrollees FOLFIRINOX treatment had to be paused temporarily due to the enrollees severe diarrhea, which has been unresponsive Loperamide, Lomotil, and Colestipol.The Medicare approved compendium, DrugDex, contains a citation for an acceptable off-label the use of Octreotide Acetate in the treatment of diarrhea caused be chemotherapy, specifically Irinotecan and 5-Fluorouracil. As noted previously, the enrollee has received both Irinotecan and 5-Fluorouracil. Therefore, the documentation does support that the Octreotide Acetate is being prescribed for a medically accepted indication, as outlined in DrugDex.The plan has no quantity limit or step therapy requirements for Octreotide Acetate. The plan does have prior authorization requirements for the coverage of Octreotide Acetate. However, these requirements are diagnosis specific and are not relevant to the enrollees diagnosis. Since the documentation supports that the medication is being used for a medically accepted indication outlined in DrugDex, an exception can be granted to the plans diagnosis-specific prior authorization requirements. A physician reviewed the appeal and determined that the plan is required to cover the Octreotide Acetate.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Eliquis 5 milligram tablet prescribed twice daily for deep vein thrombosis. 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 this medication was needed. We received the documentation and included it in our review.The medical records show the doctor prescribed Eliquis to treat the enrollees deep vein thrombosis, hypercoagulable state, and history of thrombophlebitis. The plan has prior authorization requirements for this high risk drug that must be met before they will cover the requested drug. The records show the enrollee has a history of three prior deep vein thromboses. The prescriber states chronic kidney disease is stable and attests to the medical necessity and safety of this high risk medication. The documentation provided shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Eliquis.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Imbruvica 140 milligram capsules prescribed for non-small cell lung cancer, EGFR mutated. 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 Imbruvica for non-small cell lung cancer, EGFR mutated. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. There are no Medicare approved journal articles to 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 Carvedilol Phosphate 20 milligram extended release capsules prescribed for the enrollees condition. 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.