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

You asked the Plan to cover Ubrelvy. The Plan did 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 request for Ubrelvy 100 mg tab, 10 tablets per 28 days. The drug is requested to treat chronic migraine without aura not intractable. The Plan limits the amount of Ubrelvy 100 mg tab to 8 tablets per 30 days. The prescriber states the request is for 10 tablets per 28 days because Our pharmacy can only fill Ubrelvy is packs of 10 tablets (sic). The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the enrollee's condition and/or would likely cause harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is not supported. Our Physician Reviewer's opinion is that quantity limit exception criteria are not 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 and necessary, 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 not met. Therefore, the Plan is not required to cover the requested quantity of Ubrelvy.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Ruconest. The Plan did 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 request for Ruconest 2100 unit vial (4 vials per 30 days). Ruconest 2100 unit vial is requested to treat acute attacks of hereditary angioedema. The enrollee does not satisfy the Plan's coverage criteria. The prescriber was asked to provide office notes and laboratory reports. The prescriber clarified the enrollee's diagnosis. The prescriber also clarified the requested drug quantity. As well, the laboratory reports show that the enrollee has low C1 Esterase Inhibitor function (11%). The office notes show that the requested drug is being used for the treatment of acute attacks. The prescriber has indicated why all alternatives required by the Plan would likely not be as effective as the requested drug for the enrollee, and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is medically necessary. Our Physician Reviewer's opinion is that prior authorization exception criteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. A Plan must grant an exception to prior approval rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on the available documentation, our Physician Reviewer's opinion is that an exception to prior approval criteria is met. Therefore, our decision is the Plan is required to cover Ruconest.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Actemra. 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 Actemra 400 mg/20mL. The drug is requested to treat rheumatoid arthritis. Upon reconsideration, theprescribing physician has submitted a sufficiently strong statement supported by medical records as to whythe formulary alternatives are inappropriate for the enrollee. The prescriber states that the enrollee has ahistory of perforated bowel and as such Rinvoq would be inappropriate for the enrollee. The prescriber hasindicated why all alternatives required by the Plan would likely not be as effective as the requested drug forthe enrollee, and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, anexception to the Plan's coverage criteria is medically necessary. Our Physician Reviewer's opinion is thatformulary exception criteria are metA 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 met. Therefore,the Plan is required to cover Actemra.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Ubrelvy. The Plan did not grant this request. We received this case to conduct an independent review.Medicare law and Plan rules do not allow tiering exceptions for non-formulary drugs being covered through a formulary exception. The documentation in the record shows that Ubrelvy is currently being covered for the enrollee through a formulary exception. Therefore, our decision is the Plan is not required to provide a tiering exception for Ubrelvy.
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 Siladryl. The Plan did not grant this request. We received this case to conductan independent review.Medicare Part D does not cover non-prescription drugs. We checked FDA approved sources for the drug'sclassification or determined from other available resources that the drug is a non-prescription or OTC drug.Therefore, Siladryl is not eligible for Part D coverage, and the Plan is not required to cover it under the PartD benefit.This decision does not address the medical necessity or appropriateness of the requested drug. It onlyestablishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Favorable

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 and provide reimbursement for Lactulose Solution 10 gm/15 ml receivedFebruary 3, 2020 while you were a patient at the hospital. The Plan did not grant this request. We receivedthis case to conduct an independent review.The Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances.The record shows you received Lactulose Solution February 3, 2020 while you were a patient at thehospital. You then submitted a request for reimbursement to the Plan with an itemized statement and proofof payment of the self-administered portion. The Plan's out-of-network coverage rules were followed.Therefore, our decision is the Plan is required to process applicable reimbursement for Lactulose Solution10 gm/15 ml received February 3, 2020 while you were a patient at the hospital.Please note, the Plan may have had other coverage rules for this drug, such as prior authorization, whichhave not been reviewed as part of this appeal. MAXIMUS is directing the Plan to process this claim asrules for obtaining out-of-network review have now been met. The Plan may notify you if there are anyother coverage issues that need to be addressed when they process this claim.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide reimbursement for Ophthalmic (BSS) Compound purchased January 13, 2020. The Plan did not grant this request. We received this case to conduct an independent review.A written request for Reconsideration must be filed within 60 days from the date of the Plan's Redetermination Letter. This request was not filed within the required 60-day time limit. However, the case record reflects there is good cause for the late filing. Therefore the Reconsideration request is being processed.The case record indicates that the Ophthalmic (BSS) Compound contains your blood and a sterile, preservative-free balanced salt solution. Medicare Part D does not cover drugs that are not FDA approved. Medicare rules state that only costs for the Part D drug components in a compound may be covered under Medicare Part D. In this case, blood serum is not a Part D drug because it is not an FDA approved drug product or biological. For that reason, it is not eligible for coverage under Medicare Part D. An exception to the Plan's formulary cannot be made to grant coverage for a drug that does not meet the definition of a Part D drug. Therefore, the Plan is not required to cover or provide reimbursement for blood serum used in Ophthalmic (BSS) Compound purchased January 13, 2020. For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. If a drug is not used for a medically accepted indication of therapeutic value on the body, it cannot satisfy the definition of a Part D drug. The sterile, preservative-free balanced salt solution is used to dilute the blood serum in the compounded Ophthalmic (BSS) Compound purchased January 13, 2020. The sterile, preservative-free balanced salt solution's use in this instance is not therapeutic. Thus, the sterile, preservative-free balanced salt solution does not, as used, meet the definition of a Part D drug. Therefore, the Plan is not required to cover the sterile, preservative-free balanced salt solution used in the Ophthalmic (BSS) Compound purchased January 13, 2020. Since the components of Ophthalmic (BSS) Compound purchased January 13, 2020 do not meet the definition of a Part D drug, the Plan does not have to cover or provide reimbursement for this compound drug. This decision does not address the medical necessity or appropriateness of the requested compound drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Entresto. The Plan did 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 request for a tiering exception for Entresto 49-51 mg. The drug is requested to treat heart failure. The drug is on Tier 3 of the Plan's formulary. There are no available lower tier brand drugs on the Plan's formulary to treat the enrollee's 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 the same type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) in a lower cost-sharing tier approved for treating the same condition that the higher cost-sharing tiered drug is being used to treat. Our Physician Reviewer's opinion is that tiering exception criteria are not met because there 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 Entresto.
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 Memantine. 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 Memantine 14 mg capsule. The drug is requested to treat dementia. You have not indicated why allalternatives required by the Plan would likely not be as effective for the enrollee as the requested drug;and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to thePlan's coverage criteria is not supported.Our Physician 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 Memantine.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide reimbursement for Methadone received April 2019 through April 2020 from a clinic. The Plan did not grant this request. We received this case to conduct an independent review.A written request for Reconsideration must be filed within 60 days from the date of the Plan's Redetermination Letter. This request was not filed within the required 60-day time limit. However, the case record reflects there is good cause for the late filing. Therefore the Reconsideration request is being processed.Medicare Part D does not cover Methadone when not dispensed upon a prescription at a retail pharmacy. The case record indicates that you received Methadone from a treatment center and it was not dispensed upon a prescription at a retail pharmacy. Thus, Methadone is not eligible for Part D coverage. Our decision is the Plan is not required to cover or provide reimbursement for Methadone received April 2019 through April 2020 from a clinic under the Part D benefit. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Hizentra. The Plan did 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 request for Hizentra. The drug is requested to treat chronic Inflammatory demyelinating polyradiculoneuropathy. The prescriber has not indicated why all alternatives required by the Plan would likely not be as effective for you as the requested drug; and/or would likely cause adverse reaction(s) or other harm to you. Therefore, an exception to the Plan's coverage criteria is not supported. Our Physician 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 requested drug is medically necessary, consistent with the prescriber's statement. Based on a review of the available documentation, our Physician Reviewer's opinion is that formulary exception criteria are not met. Therefore, the Plan is not required to cover Hizentra.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Belsomra. The Plan did 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 request for Belsomra 20mg. The drug is requested to treat sleep apnea. You have not indicated why all alternatives required by the Plan would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is not supported.Our Physician 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 requested drug is medically necessary, consistent with the prescriber's statement. Based on a review of the available documentation, our Physician Reviewer's opinion is that formulary exception criteria are not met. Therefore, the Plan is not required to cover Belsomra.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Lidocaine 5% Patch. The Plan did 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 request for Lidocaine 5% Patch. The drug is requested to treat low back pain secondary to lumbosacral disc degeneration, right lumbar radiculopathy and fibromyalgia, which is an off-label (non-FDA approved) use. The prescriber was asked to clarify the enrollee's diagnosis, to address the Plan's prior authorization criteria, and to provide supporting medical records. The prescriber clarified the medical history in a statement dated 8/24/2020. Medical records from date of service 8/14/2020 were provided. 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. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible 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 accepted indication. A medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia. Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicare approved compendia that support the use of Lidocaine 5% Patch 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, it cannot be covered under the Medicare Part D benefit for this condition. An exceptions request based on medical necessity cannot be considered 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 Lidocaine 5% Patch. This decision does not concern the medical necessity of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Hydroxychloroquine. The Plan did 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 request for Hydroxychloroquine Sulfate 200mg, #30 per 30 days. Hydroxychloroquine Sulfate 200mg, #30 per 30 days, is requested for treatment of polymorphic light eruption and plaque psoriasis. The prescriber states that the enrollee has been labeled psoriasis for years, and it is noted that the enrollee has failed topical treatment as well as Humira; however the prescriber states that the working diagnosis is now polymorphic light eruption. Skin biopsy pathology was consistent with the diagnosis of polymorphic light eruption. Coverage was Hydroxychloroquine was denied because the plan determined that the drug is not being prescribed for a medically accepted indication, and because the plan states they have a quantity limit restriction due to the Covid 19 pandemic. Per the plan's Evidence of Coverage, and HPMS (Health Plan Management System - CMS's official database for Plan formularies), there are no utilization management criteria for coverage of the requested drug. Our Physician Reviewer found that the Medicare-approved resources do contain citations to support the use of this drug for this condition. The following is stated in the Uses section of AHFSDI (American Hospital Formulary Services Drug Information): Hydroxychloroquine has been effective in some cases when used in the treatment of polymorphous light eruptions. Therefore the requested drug is being prescribed to treat a medically accepted indication as defined by Medicare. There are no applicable utilization management criteria identified for coverage of the requested drug. Our Physician Reviewer's opinion is that Medicare Part D criteria for coverage of the requested drug have been met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior authorization, step therapy or quantity limits. Hydroxychloroquine is on the Plan's formulary and is not subject to any of these restrictions. Therefore, our decision is the Plan is required to cover Hydroxychloroquine.
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 us as required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Lidocaine 5% Ointment. The Plan did 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 request for Lidocaine 5% Ointment. The drug is requested to treat onychocryptosis of bilateral great toes. You were asked to clarify the enrollee's diagnosis, because it was unclear from the case file what was the underlying etiology of the enrollee's condition. You were also asked to provide supporting medical records. A response from you was not received. Therefore, based on the current record, there is insufficient documentation that the requested medication is being prescribed for a medically accepted indication as defined by Medicare law. In addition, prior authorization exception criteria are not met.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. A medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia. Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicare approved compendia that support the use of Lidocaine 5% 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, it cannot be covered under the Medicare Part D benefit for this condition. An exceptions request based on medical necessity cannot be considered 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 Lidocaine 5% Ointment. This decision does not concern the medical necessity of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.