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

At issue is a tiering exception request for Calcium Acetate 667 milligram capsules prescribed for hyperphosphatemia associated with end-stage renal disease. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we 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. Calcium Acetate capsules are a generic drug on Tier 3 of the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the generic drugs of the same type on the lower tiers of the plans formulary to treat the enrollees condition have been tried and failed, or are contraindicated. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nulojix 250 milligram/milliliter solution prescribed following a lung transplant. 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 also researched Medicare systems and reviewed the enrollment data available. Based on the information provided, the biologic is eligible for Part B coverage. The plan does not offer supplemental (additional) coverage for this biologic. 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 Kineret solution 100 milligram/0.67 milliliter prefilled syringe prescribed for rheumatoid 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. The documentation shows the enrollee is enrolled in Kineret On Track Patient Assistance Program from February 3, 2021, through December 31, 2021. When the enrollee decided to use a patient assistance program they acknowledged and agreed that the Kineret On Track will be treated as the primary payer with respect to medications that they have selected to purchase through them. In this instance, the QIC has determined that cover cannot be allowed for the as coverage has already been allowed by Kineret On Track Patient Assistance Program. Some members are enrolled in a patient assistance program offered by a drug manufacturer that is outside the plan benefits. Because the enrollee is getting their drug through the patient assistance program and not through the plan's benefits, the Plan will not pay for any share of these drug costs. Thus, Kineret is not eligible for coverage or reimbursement by Part D. In conclusion, the decision of the QIC is unfavorable.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Ajovy 225 milligram per 1.5 milliliter prefilled subcutaneous injection syringe. The Part D plan denied the request stating that the drug was being prescribed for a non-medically accepted indication.We received the case to perform an independent and de novo review. To make our decision, we 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 submitted medical records indicate that Ajovy has been prescribed for migraine prophylaxis, which is a medically accepted indication for the use of Ajovy outlined in the Medicare approved compendia. However, Ajovy is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all 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 Cyclophosphamide 50 milligram capsules prescribed for multiple myeloma. 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 record shows the prescriber ordered Cyclophosphamide for multiple myeloma. The Medicare approved compendia support this is a medically accepted indication for the drug. However, 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 Cyclophosphamide.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xtampza 27 milligram extended release abuse deterrent capsules prescribed for chronic pain. 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. In this case, the medical records do not support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed the appeal and determined that the plan is not required to cover Xtampza.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dronabinol 5 milligram capsules prescribed to treat unintentional weight loss. The Part D plan denied the tiering exception request stating that the provided diagnosis (nausea) was a non-medically accepted indication.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.The office visit note dated May 20, 2021, shows the enrollees diagnosis of nausea was resolved. This documentation also shows the doctor prescribed Dronabinol 5 milligram capsules to treat unintentional weight loss. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover Dronabinol 5 milligram capsules.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a prior authorization request for Prolia 60 milligram/milliliter injection prescribed for post-menopausal osteoporosis. 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. The enrollee satisfies the plan's coverage criteria. The prescriber submitted a statement to support the enrollee was prescribed Prolia for post-menopausal osteoporosis. Furthermore, the enrollee will not be using Prolia in conjunction with other medications for osteoporosis. Finally, the enrollee is unable to take an oral bisphosphonate due to difficulty swallowing.A physician reviewed the appeal and determined that the requested biologic is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested prior authorization for Xifaxan 550 milligram tablets prescribed as directed for refractory pouchitis after ulcerative colitis. 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. The documentation shows your doctor prescribed Xifaxan to treat your refractory pouchitis after ulcerative colitis. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Epolamine 1.3% Patch to treat acute pain due trauma and sprain of unspecified ligament of right ankle/chronic ankle sprain. 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. The documentation shows your doctor prescribed Diclofenac Epolamine 1.3% Patch to treat your acute pain due to trauma and sprain of unspecified ligament of right ankle/chronic ankle sprain. However, the Medicare approved compendia do not support the use of this drug for your condition. 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 Metaxalone 800 milligram tablets prescribed for chronic pain syndrome. 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 Metaxalone for chronic pain syndrome. 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 Anoro Ellipta 62.5/25 microgram inhaler prescribed for chronic obstructive pulmonary 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 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. In this case, the medical records do not support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed the appeal and determined that the plan is not required to cover Anoro Ellipta.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Sodium Chloride 0.9% vial prescribed for zoster keratitis. The Part D plan denied the request. We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows the enrollee requested the plan to provide reimbursement for Sodium Chloride. However, the plan indicates that a claim for the Sodium Chloride already processed.  Therefore, we determined that the plan is not required to further reimburse the enrollee. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Micafungin 100 milligram solution prescribed for osteomyelitis due to a candida infection. 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.We requested additional documentation from the prescriber. Specifically, we requested medical records and a prescriber statement to support all formulary alternatives were tried and failed. We received the requested documentation and included in the review.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 the enrollee. A physician reviewed the appeal and determined that the plan is not required to cover Micafungin.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested NP Thyroid 30 milligram tablet prescribed daily for unknown condition. The Part D plan denied the enrollees 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. We determined that the plan is not required to cover or provide reimbursement for the NP Thyroid. According to Microdex, NP Thyroid has not been found by the Food and Drug Administration to be safe and effective; and the drug product label has not been approved. Therefore, the drug is excluded from coverage under Medicare Part D. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Desipramine Hydrochloride 100-milligram tablet to treat primary insomnia. 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. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We received the documentation and included it in our review. We receive a prescriber statement, diagnoses, and medical records.The documentation shows your doctor prescribed Desipramine Hydrochloride to treat your primary insomnia and lumbar radiculopathy. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Desipramine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Galantamine extended-release 8 milligram capsules, The Part D plan denied the appeal 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.Galantamine is a generic drug on Tier 4 of the plans formulary. The medical records do not support that all drugs available on lower tiers to treat the enrollees condition have been tried or deemed contraindicated. 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 request for coverage of Northera 100 milligram capsules, 180 capsules per 30 days. The Part D plan denied the request for coverage because the amount requested exceeded the plans quantity limit. Additionally, the drug was being prescribed for a non-medically accepted indication.We received the case to perform an independent and de novo review. To make our decision, we 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 Northera has been prescribed for the treatment of recurrent syncopal episodes. 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. Since the drug is not eligible for coverage, the plans quantity limit for the drug 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 Heparin Sodium 20000 unit/milliliter solution prescribed for blood clot prophylaxis. 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. According to Medicare rules, the requested drug cannot be approved for separate payment under Part D when it is for treatment of an enrollee who is receiving dialysis. Medicare records show the enrollee is actively receiving dialysis. Therefore, the Heparin Sodium must be billed by the renal dialysis facility. We determined that the plan is not required to cover the Heparin Sodium.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Yupelri 175-micrograms/3-milliliter Solution to treat chronic obstructive pulmonary disease. The Part D plan denied the request. The requested drug is not on the plans formulary. 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.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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Deferasirox 360 milligram tablet prescribed for myelodysplastic 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 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 statement from the prescribers office indicates Deferasirox 360 milligram tablets are requested to treat iron overload in an enrollee with low-risk myelodysplastic syndrome. However, the 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 Deferasirox.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Voriconazole 200 milligram tablets prescribed for hip infection with mold, Paecilomyces. 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 Voriconazole for hip infection with mold, Paecilomyces. 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 Testosterone 30-milligrams/1.5-milliliter Pump to treat testosterone deficiency. 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 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 Vosevi 400/100/100 milligram tablets prescribed as directed for chronic hepatitis C. 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Vosevi to treat your chronic hepatitis C. Your 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 your appeal and determined that the plan is not required to cover Vosevi.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is One Touch Verio Test Strip prescribed for an enrollee with a diagnosis of type 2 diabetes mellitus. 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 records indicate the One Touch Verio Test Strips are requested for an enrollee with type 2 diabetes mellitus. Test strips, lancets, and needle disposal systems are not considered medical supplies directly associated with the delivery of insulin for purposes of coverage under Part D. However, this item may be eligible for coverage under Medicare Part B. We determined that the plan is not required to cover One Touch Verio Test Strip.