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

At issue is coverage for LiQ-10 Syrup to treat primary CoQ10 deficiency with manifestation of cerebellar ataxia, localization-related epilepsy and stroke-like episodes. 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 requested drug is available over the counter without a prescription. Nonprescription drugs, even when a prescription has been written, are excluded from coverage under Medicare Part D. This is regardless of whether the drug is being prescribed as a supplement or as a treatment. Therefore, the requested drug is excluded from 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 Rytary ER (extended release) 61.25-245 milligram capsule to treat Parkinsons 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.Rytary ER 61.25-245 milligram capsule is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower tiers of the plans formulary. 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 reviewer determined that tiering exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Uptravi 1600 microgram tablet to treat pulmonary arterial hypertension. 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 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 and failed, or deemed contraindicated. In this case, the prescriber has not addressed all formulary alternatives required by the plan to treat the enrollees condition and provided patient specific clinical rationale as to why each formulary alternative would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Therefore, the formulary exception criteria have not 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 a tiering exception request for Eliquis 2.5 milligram tablet prescribed as anticoagulation therapy in an enrollee with persistent atrial fibrillation and coronary artery 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.Eliquis 2.5 milligram tablet is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower tiers of the plans formulary. 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 reviewer determined that tiering exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Sevelamer Carbonate 800 milligram tablet to treat hyperphosphatemia. 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 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 and failed, or deemed contraindicated. In this case, the prescriber has not addressed the formulary alternatives required by the plan to treat the enrollees condition and provided patient specific clinical rationale as to why each formulary alternative would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Therefore, the formulary exception criteria have not 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 Alprazolam XR 0.5 milligram tablets to treat anxiety 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 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: Favorable

At issue is Lynparza 100 milligram tablets to treat HRD positive mutated metastatic prostate cancer. 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 documentation indicates the prescriber ordered the drug at issue for the enrollees diagnosis. The Medicare approved compendia contain a citation to support the use of the drug for the noted diagnosis. As such, the submitted documentation supports the drug was prescribed for a medically accepted indication. The plan has prior authorization coverage criteria that must be met prior to approval. The enrollee satisfies the Plans coverage criteria. The submitted documentation supports the enrollee has had disease progression while on Lupron and has had androgen receptor directed therapy. 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 Megestrol Acetate 40 milligram tablets to treat loss of appetite and malnutrition due to Alzheimer's 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.Drugs prescribed to treat anorexia and/or weight loss, unrelated to AIDS wasting or cachexia due to certain chronic diseases, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is coverage for Morphine Sulfate ER (extended release) 30 milligram tablets, 90 tablets per 30 days. The Part D plan denied the request for coverage because the documentation did not support the medical necessity for exceeding a cumulative dosage of greater than 200 milligram morphine equivalents (MME) of opioid-containing drugs the enrollee has on hand per day.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 documentation supports that the requested drug has been prescribed to treat chronic axial neck pain and radicular low back pain, which is a medically accepted indication for the drug outlined in the Medicare approved compendia. The plan limits the amount of opioid-containing drugs the enrollee has on hand per day to 200 MMEs. The prescriber has submitted a form at reconsideration that shows the enrollee has 125.67 MMEs on hand per day for a 30-day average, which is less than 200 MMEs. The progress notes submitted at reconsideration also confirm that the enrollee does not have more than 200 MMEs of opioid-containing drugs on hand per day. The progress notes show that the enrollee is currently prescribed Morphine Sulfate ER 30 milligram tablets (the drug under review) to be taken every 8 hours, which is 90 MMEs. The notes show that the enrollee is also prescribed Hydrocodone-Acetaminophen 10-325 milligram tablets every 6 hours as needed for pain, which is 40 MMEs. As such, the progress notes indicate the enrollee has 130 MMEs of opioid-containing drugs on hand per day, which does not exceed the plans quantity limit for opioid-containing drugs. Therefore, the documentation submitted at reconsideration confirms the plans limit of 200 MMEs per day has not been exceeded and coverage for the drug is supported.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 coverage for Repatha Sureclick 140 milligram per milliliter subcutaneous auto injection pen to treat hyperlipidemia in an enrollee with coronary artery disease. 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 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 and failed, or deemed contraindicated. In this case, the prescriber has not addressed the formulary alternative drug required by the plan to treat the enrollees condition and provided patient specific clinical rationale as to why this formulary alternative would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Therefore, the formulary exception criteria have not been met. It should be noted that the formulary alternative drug, Praluent, belongs to the same drug classification as the requested drug. Both drugs are proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitors. 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 Wegovy 2.4 milligram per 0.75 milliliter subcutaneous auto injection pen prescribed for weight reduction in an enrollee with diabetes, obesity, and osteoarthritis. 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.Drugs prescribed to treat/promote weight loss (even if used for a non-cosmetic purpose, such as morbid obesity) are excluded from the Part D coverage. It should also be noted that the brand drug, Wegovy, is not Food and Drug Administration (FDA)-approved to treat diabetes. The only FDA-approved indication for the brand drug, Wegovy, is an as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an elevated body mass index (BMI). However, as noted previously, drugs used to treat/promote weight loss are excluded from Part D coverage. As such, the requested drug is excluded from 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 coverage for Januvia 100 milligram tablet to treat type 2 diabetes mellitus. The Part D plan denied the request for coverage and then auto-forwarded the case to us for review. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted.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 and failed, or deemed contraindicated. In this case, the prescriber has not addressed the formulary alternative drug required by the plan to treat the enrollees condition and provided patient specific clinical rationale as to why the formulary alternative would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Therefore, the formulary exception criteria have not 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 Xifaxan 550 milligram tablets to treat chronic diarrhea, gastroenteritis and colitis due to radiation, and intermittent small intestinal bacterial overgrowth. 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 a tiering exception request for Linzess 145 microgram capsules to treat Irritable bowel syndrome with constipation. 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.Linzess 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: Favorable

At issue is coverage for Xifaxan 550 milligram tablets, 60 tablets per 30 days, to treat hepatic encephalopathy. The Part D plan denied the request for coverage due because the following prior authorization requirement was not met: must be receiving maximum tolerated dose of Lactulose and still having breakthrough overt episodes of hepatic encephalopathy.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 documentation submitted at reconsideration indicates that the enrollee was started on Lactulose therapy after Xifaxan was initially denied coverage by the plan. The prescriber notes that the enrollee has been taking it [Lactulose] with episode recurrence as well as bad side effects'. The progress notes submitted at reconsideration dated August 3, 2022, support this statement, as it is noted that Lactulose caused the enrollee to have severe nausea and the drug had to be discontinued. As such, the prescriber statement and medical records submitted at reconsideration support an exception to the plans prior authorization requirement that the enrollee must be on the maximum tolerated dose of Lactulose, as the enrollee has symptomatic intolerance to Lactulose.The submitted documentation supports that all of the plans other prior authorization requirements for the drug have been met. The drug is being prescribed to treat hepatic encephalopathy, which is a medically accepted indication for the drug outlined in the Medicare approved compendia. The enrollee is more than 12 years old. The medical records include current and previous therapies tried, including Spironolactone, Lasix, Nadolol, Protonix, and most recently, Lactulose. As such, the documentation validates that all of the plans prior authorization requirements for coverage of the requested drug for the treatment of hepatic encephalopathy have been met with the exception of the requirement that the enrollee must be receiving the maximum tolerated dose of Lactulose. However, as noted previously, an exception to that prior authorization requirement is supported, as the enrollee cannot tolerate Lactulose. Therefore, coverage for the drug is supported.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 Gammagard 10 percent solution to treat relapsing/remitting multiple sclerosis. 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 Envarsus XR 1 milligram tablets prescribed daily for heart 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 reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. We determined that the plan is not required to cover the drug. Medicare records indicate the enrollee received a heart transplant, which was covered by Medicare Part A. Therefore, the transplant is considered a Medicare covered transplant and the requested drug is eligible under Medicare Part B. Medicare rules state that a drug covered under Part B cannot be covered under Part D. 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 Folic Acid 1 milligram tablets to treat folic acid deficiency. 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.Drugs prescribed for use as vitamins and minerals 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 Calcitriol 1 microgram per milliliter solution. 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 Xeloda 500-milligram tablets to treat malignant neoplasm of rectum. 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 drug at issue is an oral cancer drug that has the same active ingredient as an injectable drug. Oral cancer drugs that contain the same active ingredient as injectable dosage forms are covered under Medicare Part B. The drug at issue is not considered a Part D benefit.We determined that the plan is not required to cover the Xeloda.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ofev 100 milligram capsules to treat chronic fibrosing interstitial lung 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 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 coverage for Gamunex-C 5 gram per 50 milliliter vial for intravenous infusion to treat monoclonal gammopathy of undetermined significance (MGUS) with associated neuropathy. 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 noted condition is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-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 Oxycontin ER 80 milligram tablets to treat chronic pain syndrome. 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.