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

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Tobrex 0.3% ointment. The Plan did not grant this request. We received thiscase to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Tobrex 0.3% ointment. The drug is requested to treat an unspecified diagnosis, which is an off-label(non-FDA approved) use. The Medicare-approved compendia do not contain any citations to support theuse of the requested drug, as prescribed, for treatment of the noted condition.Additional medical information was requested by the Part D QIC. The prescribing physician was asked toaddress the formulary alternatives and to provide the enrollee's diagnosis. A response from the prescribingphysician was not received. Therefore, based on the current record, the requested drug is not beingprescribed for a medically accepted indication as defined by Medicare law. As such, an exceptions requestbased on medical necessity cannot be considered because the requested drug, as prescribed, does not meetthe definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage underMedicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically acceptedindication. A medically accepted indication means a use that is approved by the FDA or a use that issupported by one or more citations in Medicare approved compendia.Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicareapproved compendia that support the use of Tobrex 0.3% ointment for the diagnosed condition. As a result,the drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, itcannot be covered under the Medicare Part D benefit for this condition. An exceptions request based onmedical necessity cannot be considered because this drug, as prescribed, does not meet the definition of aMedicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage forTobrex 0.3% ointment.This decision does not concern the medical necessity of the requested drug. It only establishes if paymentcan be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Rituxan. The Plan did not grant this request. Wereceived this case to conduct an independent review.Medicare law and Plan rules do not allow tiering exceptions for non-formulary drugs being coveredthrough a formulary exception. The documentation in the record shows that Rituxan is currently beingcovered for the enrollee through a formulary exception. Therefore, our decision is the Plan is not requiredto provide a tiering exception for Rituxan.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Hydroxyzine HCL. The Plan did not grant this request. We received this caseto conduct an independent review.We asked a Physician Reviewer to determine whether the Plan was correct in denying the request forHydroxyzine HCL, which is not on the Plan's formulary. Our Physician Reviewer needed additionalinformation from you to make this determination. You were asked to address whether the drugs offered bythe Plan would: (1) not be as effective as the requested non-formulary drug; and/or (2) have adverse effects.The requested information was not received. Based on a review of the available documentation, ourPhysician Reviewer's opinion is that formulary exception criteria are not met.A Plan must grant an exception for a drug that is not on its formulary if it determines that the requesteddrug is medically necessary, consistent with the prescriber's statement. Based on a review of the availabledocumentation, our Physician Reviewer's opinion is that formulary exception criteria are not met.Therefore, the Plan is not required to cover Hydroxyzine HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Zolpidem. The Plan did not grant this request. We received this case toconduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Zolpidem.Zolpidem is requested to treat insomnia, pain in right knee, and chronic pain syndrome. A returned providerstatement was reviewed. The documentation does not support the diagnoses or trial of medications asoutlined in prior authorization criteria. For coverage under the prescription drug benefit, Medicare requiresthat the drug prescribed be used for a medically accepted indication. Our Physician Reviewer found that theMedicare-approved resources do contain citations to support the use of the requested drug for treatment ofthe noted condition. Therefore, the requested drug is being prescribed for a medically accepted indication.The enrollee does not satisfy the Plan's coverage criteria. You have not sufficiently addressed the Plan'scoverage criteria and/or have not indicated why all alternatives required by the Plan would likely not be aseffective for the enrollee as the requested drug, and/or would likely cause adverse reaction(s) or other harmto the enrollee. Our Physician's opinion is that neither prior authorization nor prior authorization exceptioncriteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. APlan must grant an exception to prior approval rules if it determines that the requested drug is medicallynecessary, consistent with the prescriber's statement. Based on the available documentation, our PhysicianReviewer's opinion is that an exception to prior approval criteria is not met. Therefore, the Plan is notrequired to cover Zolpidem.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for Albuterol HFA purchased on March 17, 2020, from thepharmacy. The Plan did not grant this request. We received this case to conduct an independent review.Medicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. If you pay thefull cost of a prescription drug out-of-pocket you can ask the Plan to pay you back. When submitting arequest for reimbursement, the Plan requires that you submit your receipt documenting the payment youhave made along with your reimbursement request. You submitted a request for reimbursement to the Planfor Albuterol HFA purchased March 17, 2020, from the pharmacy. The case record does not include proofof payment. Therefore, our decision is the Plan is not required to provide reimbursement for Albuterol HFApurchased March 17, 2020 from the pharmacy.Please note once you have paid your bill in full you can resubmit your request for review to your Part DPlan.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Hydrocodone-Acetaminophen, 10-325 mg tablet, 270 per 30 days. The Plandid not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Hydrocodone-Acetaminophen, 10-325 mg tablet, 270 tablets for 30 days. The drug is requested to treatrheumatoid arthritis and chronic neck and spine pain. The Plan limits the amount of the drug to 180 tabletsfor 30 days. The prescriber has indicated that the number of doses of the requested drug allowed by thePlan would likely be ineffective in treating the enrollee's condition, and/or would likely cause harm to theenrollee. Therefore, an exception to the Plan's coverage criteria is medically necessary. Our PhysicianReviewer's opinion is that quantity limit exception criteria are met.Medicare rules allow a Part D Plan to manage its formulary by covering a limited quantity of certain drugs.A Plan must grant an exception if it determines that the requested dosage is medically reasonable andnecessary, consistent with the prescriber's statement. Based on a review of the available documentation,our Physician Reviewer's opinion is that an exception to the quantity limit criteria is met. Therefore, thePlan is required to cover the requested quantity of Hydrocodone-Acetaminophen, 10-325 mg tablet, 270 per30 days.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover or provide reimbursement for Ezetimibe and Jardiance purchased onSeptember 8 and October 8, 2019, from the pharmacy. The Plan did not grant this request. We received thiscase to conduct an independent review.Medicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. If you pay thefull cost of a prescription drug out-of-pocket you can ask the Plan to pay you back. When submitting arequest for reimbursement, the Plan requires that you submit your receipt documenting the payment youhave made along with your reimbursement request. You submitted a request for reimbursement to the Planfor Ezetimibe and Jardiance purchased on September 8 and October 8, 2019, from the pharmacy. The caserecord does not include proof of payment. Therefore, our decision is the Plan is not required to providereimbursement for Ezetimibe and Jardiance purchased on September 8 and October 8, 2019, from thepharmacy.Please note once you have paid your bill in full you can resubmit your request for review to your Part DPlan.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Xeljanz XR, 11 mg tablet. The Plan did not grant this request. We receivedthis case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Xeljanz XR, 11 mg tablet.The drug is requested to treat polymyositis with myopathy, which is an off-label (non-FDA approved) use.The Medicare-approved compendia do not contain any citations to support the use of the requested drug, asprescribed, for treatment of the noted condition. Therefore, the requested drug is not being prescribed for amedically accepted indication as defined by Medicare law. As such, an exceptions request based onmedical necessity cannot be considered because the requested drug, as prescribed, does not meet thedefinition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage underMedicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically acceptedindication. A medically accepted indication means a use that is approved by the FDA or a use that issupported by one or more citations in Medicare approved compendia.Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicareapproved compendia that support the use of Xeljanz XR, 11 mg tablet for the diagnosed condition. As aresult, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. Assuch, it cannot be covered under the Medicare Part D benefit for this condition. An exceptions requestbased on medical necessity cannot be considered because this drug, as prescribed, does not meet thedefinition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to providecoverage for Xeljanz XR, 11 mg tablet.This decision does not concern the medical necessity of the requested drug. It only establishes if paymentcan be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Trintellix. The Plan did not grant this request. We received this case to conductan independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Trintellix. Trintellix is requested to treat an unknown diagnosis. The prescriber was asked to state theenrollee's diagnosis, because there was no prescriber statement of the enrollee's diagnosis in the case file.The prescriber was also asked to address medical necessity for the requested drug. A response from theprescriber was not received. Therefore, based on the current record, there is insufficient documentation thatthe requested medication is being prescribed for a medically accepted indication as defined by Medicarelaw. In addition, a tiering exception request based on medical necessity cannot be considered because itcannot be confirmed that the drug meets the definition of a Medicare Part D drug.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically acceptedindication. A medically accepted indication means a use that is approved by the FDA or a use that issupported by one or more citations in Medicare approved compendia.Our Physician Reviewer needed additional information from the prescriber to determine whether theenrollee is using Trintellix for an FDA-approved use, or a use listed in the Medicare-approved compendia.The requested information was not received. As a result, we could not confirm that the drug is beingprescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be coveredunder the Medicare Part D benefit. An exceptions request based on medical necessity cannot be consideredbecause it cannot be confirmed that the drug meets the definition of a Medicare Part D drug. Therefore, ourdecision is that the Plan is not required to provide coverage for Trintellix.This decision does not concern the medical necessity of the requested drug. It only establishes if paymentcan be made under the Medicare Part D benefit.Please note: the request for a tiering exception (lower copayment) for Trintellix was not reviewed. Wecannot consider a tiering exception for a drug for which the Part D Plan is unable to provide coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to provide a tiering exception for Levothyroxine Sodium 50 mcg and 75 mcg. The Plandid not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor a tiering exception for Levothyroxine Sodium 50 mcg and 75 mcg. The drug is requested to treat yourcondition. The drug is on Tier 2 of the Plan's formulary. There are no available lower tier drugs on thePlan's formulary to treat your condition. Therefore, the drug is not eligible for a tiering exception.Our Physician Reviewer's opinion is that tiering exception criteria are not met.Medicare rules permit a Plan to grant an exception to its tiering structure so long as there is a drug of thesame type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) in alower cost-sharing tier approved for treating the same condition that the higher cost-sharing tiered drug isbeing used to treat. Our Physician Reviewer's opinion is that tiering exception criteria are not met becausethere are no lower cost-sharing tiered drugs of the same type for treating the enrollee's condition.Therefore, our decision is the Plan is not required to provide a tiering exception for Levothyroxine Sodium50 mcg and 75 mcg.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Ninlaro. The Plan did not grant this request. We received this case to conductan independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Ninlaro. The drug is requested to treat multiple myeloma in combination with Pomalidomide andDexamethasone, which is an off-label (non-FDA approved) use.The enrollee is a 69 year old man with multiple myeloma since 2017. He was treated with Revlimid,Velcade and Dexamethasone. Revlimid was switched to Pomalidomide due to rash. He also had radiation.Imaging and M-spike improved. His M-spike has been slowly increasing since January. The only lab valueincluded in the submitted documents is from February 17, 2020 with a Kappa free light chain value of 25.1.He is currently being treated with Dexamethasone, Pomalidomide and Velcade maintenance. You requestNinlaro. The office note of April 13, 2020 indicates the Ninlaro is being substituted for Velcade due toCovid-19.The Medicare-approved compendia do not contain any citations to support the use of the requested drug, asprescribed, for treatment of the noted condition. There was no peer-reviewed, clinically relevant, medicalliterature from an approved journal submitted to support this appeal. Therefore, the requested drug is notbeing prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptionsrequest based on medical necessity cannot be considered because the requested drug, as prescribed, doesnot meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverageunder Medicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically acceptedindication. For Part D drugs used in an anticancer chemotherapeutic regimen, a medically acceptedindication means a use that is approved by the FDA or a use that is supported by one or more citations inMedicare approved compendia or peer-reviewed medical literature in CMS-approved journals orpublications.Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicareapproved compendia and there was no peer-reviewed literature from an approved journal submitted tosupport the use of Ninlaro for the diagnosed condition. As a result, the drug is not being prescribed for amedically accepted indication as defined by Medicare law. As such, it cannot be covered under theMedicare Part D benefit for this condition. An exceptions request based on medical necessity cannot beconsidered because this drug, as prescribed, does not meet the definition of a Medicare Part D drug.Therefore, our decision is that the Plan is not required to provide coverage for Ninlaro.This decision does not concern the medical necessity of the requested drug. It only establishes if paymentcan be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to cover or provide reimbursement for TD vaccine received on January 7, 2020, fromthe prescribing physician's office. The Plan did not grant this request. We received this case to conduct anindependent review.The Part D Plan covers certain vaccines purchased and/or administered out-of-network. If an enrolleereceives a vaccine from an out-of-network provider, the enrollee will generally have to pay the full cost forthe vaccine. The enrollee may then submit a request for reimbursement with proof of payment to ask thePlan to pay its share of the cost.In this case, the record shows that you were administered TD vaccine on January 7, 2020. You submitted arequest for reimbursement; however, the record does not include proof of payment in full for the vaccine.The Plan's criteria for out-of-network coverage and reimbursement have not been met. Therefore, ourdecision is the Plan is not required to cover or provide reimbursement for TD vaccine received from theprescribing physician's office.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Mycophenolate Mofetil. The Plan did not grant this request. We received thiscase to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Mycophenolate Mofetil. The drug is requested to treat autoimmune necrotizing myopathy, which is anoff-label (non-FDA approved) use. The Medicare-approved compendia do not contain any citations tosupport the use of the requested drug, as prescribed, for treatment of the noted condition. Therefore, therequested drug is not being prescribed for a medically accepted indication as defined by Medicare law. Assuch, an exceptions request based on medical necessity cannot be considered because the requested drug, asprescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is noteligible for coverage under Medicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically acceptedindication. A medically accepted indication means a use that is approved by the FDA or a use that issupported by one or more citations in Medicare approved compendia.Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicareapproved compendia that support the use of Mycophenolate Mofetil for the diagnosed condition. As aresult, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. Assuch, it cannot be covered under the Medicare Part D benefit for this condition. An exceptions requestbased on medical necessity cannot be considered because this drug, as prescribed, does not meet thedefinition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to providecoverage for Mycophenolate Mofetil.This decision does not concern the medical necessity of the requested drug. It only establishes if paymentcan be made under the Medicare Part D benefit.