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

At issue is Tadalafil 10 milligram tablets prescribed for Raynauds 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.We determined that the plan is not required to cover Tadalafil because it is an erectile dysfunction drug prescribed for an off-label usage. Erectile Dysfunction drugs prescribed for off-label usage are excluded from coverage. 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 Xospata 40 milligram tablet prescribed for refractory acute myeloid leukemia. 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 documentation shows the enrollee was initially diagnoses with acute myeloid leukemia and placed on Hydrea and then Dacogen and was not considered to be a transplant candidate. The enrollee was found to be FLT3 positive along with other mutations including BCOR and NPM1 and was placed on Midostaurin and stayed in remission for 34 cycles when diagnoses with refractory disease and since that time has been on Ivosidenib with a request from the prescriber to use Xospata with Venclexta. Per the Food and Drug Administration and Medicare approved compendia, Xospata is to be used for relapsed/refractory acute myeloid leukemia with FLT3 mutation. However, the National Comprehensive Cancer Network specifically states that this should be a single agent and the Food and Drug Administration and Medicare approved compendia all reference the ADMIRAL trial where Xospata was used as a single agent and not with Venclexta. The prescriber references an oral abstract that showed a combination of Venclexta/Xospata had superior outcomes compared to single agent Xospata in patients with refractory FLT3 positive acute myeloid leukemia but this cannot be accepted as it is an abstract that is not published in a Medicare approved journal and Medicare does not accept abstracts as evidence of efficacy of a medication. A physician reviewed your appeal and determined that the plan is not required to cover Xospata.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ventolin HFA 2.5 milligrams/3 milliliter nebulizer solution prescribed for chronic obstructive pulmonary disease. 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 for use in a nebulizer in the enrollees home. This is eligible for coverage under Part B. 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 a request for coverage of Xifaxan 550 milligram tablets prescribed for the treatment of hepatic encephalopathy. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we read 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 plan has prior authorization requirements that must be met before coverage of this medication will be approved. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. 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 Buprenorphine Hydrochloride 2 milligram sublingual tablet prescribed for pain due to ankylosing spondylitis. 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 records indicate Buprenorphine Hydrochloride 2 milligram sublingual tablet is prescribed to treat chronic back pain. However, 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 Buprenorphine Hydrochloride Sublingual 2 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gammaplex 10% Solution prescribed for unspecified complication of lung transplant with raised antibody titer. 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 diagnosis reported is unspecified complication of lung transplant. However, 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 Gammaplex.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pulmozyme 1 milligram/milliliter solution prescribed for bronchiectasis and chronic bronchitis. 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 the drug at issue for the enrollees noted condition. 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 ZTlido 1.8% Patches prescribed for low back pain. 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 medical records support ZTlido 1.8% Patch is prescribed for diabetic peripheral neuropathy with pain in both lower extremities. However, 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 ZTlido 1.8% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Restasis Eye Emulsion 0.05%. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Restasis Eye Emulsion 0.05% is Brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xarelto 15 milligrams tablets prescribed to treat the enrollees condition. The Part D plan denied the appeal request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Xarelto is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Venclexta 100 milligram tablet prescribed for myelodysplastic syndrome. 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 prescriber indicates Venclexta 100 milligram tablet is prescribed to treat myelodysplastic syndrome. This drug has an orphan drug designation for the treatment of myelodysplastic syndromes. Therefore, the drug at issue can be approved. A physician reviewed your appeal and determined that the plan is required to cover Venclexta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xadago 100 milligram tablet prescribed for 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 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 requested additional information from the prescriber. 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 prescriber does not indicate why all the other alternatives on the plans formulary would not work.A physician reviewed your appeal and determined that the plan is not required to cover Xadago.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Promethazine Hydrochloride 25 milligram tablets. The Part D plan denied the request because the plans prior authorization requirements were not met.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 Promethazine Hydrochloride has been prescribed for the treatment of migraine-induced nausea. However, the Medicare approved compendia do not contain any citations to support the use of 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 prior authorization requirements are not relevant 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 a formulary exception request for Belbuca 300 microgram sublingual film prescribed for chronic pain. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The submitted documentation did not indicate that the formulary alternatives were tried and would be ineffective.A physician reviewed the appeal and determined that the plan is not required to cover Belbuca.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Botox 200 unit vial for injection. The Part D plan denied the request because the documentation did not support authorization for continuation of therapy, as at least three months had not elapsed since the enrollees last treatment with Botox. 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 medical records submitted at reconsideration indicate that the enrollee is receiving Botox injections for the treatment of spasticity of left upper extremity status post cerebrovascular accident. The use of Botox injections for the treatment of spasticity is a medically accepted indication for the drug, as outlined in the Medicare approved compendia. The medical records submitted at reconsideration include treatment notes that show the enrollee is receiving Botox treatments every three months with the last treatment date being May 20, 2021. Therefore, the records confirm that at least three months have elapsed since the enrollees last treatment with Botox. As such, the documentation verifies that the plans requirement for continuation of coverage has been met. Therefore, coverage for the drug can be allowed. 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 a prior authorization request for Estradiol 0.025 milligram/24 hour patch prescribed for vasomotor symptoms of menopause. 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 submitted documentation does not indicate that the enrollee satisfies the plan's prior authorization 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 a request for coverage of Fetroja 1 gram vial to be given by intravenous solution. The Part D plan denied the request because the drug was not included on the plans formulary and the documentation did not support a formulary exception. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The prescriber has indicated that Fetroja is being prescribed for the treatment of recurrent abscess of prostate with chronic prostatitis caused by multi-drug resistant Pseudomonas aeruginosa. However, the Medicare approved compendia do not contain any citations to support the use of Fetroja 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 under Medicare Part D, a formulary exception is not relevant 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 Dronabinol 5 milligram capsules prescribed for nausea and vomiting due to migraines. The Part D plan denied the request. The plan further denied the request for a quantity limit exception.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 the drug at issue for the enrollees noted condition. 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. As the drug at issue is not allowable, a quantity limit exception cannot be granted.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 a request for coverage of Budesonide EB 3 milligram delayed release capsules. The Part D plan denied the request for coverage because the medication was being used for a non-medically accepted indication. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The diagnoses initially provided to the plan by the prescriber include change in bowel habit and diarrhea. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted conditions. At reconsideration, the prescriber has stated the diagnosis is microscopic colitis. However, no medical records have been submitted to validate this new/additional diagnosis. Therefore, there is insufficient documentation to determine if the requested drug is being prescribed for a medically accepted indication. As such, the requested drug is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300 milligram/2 milliliter injection solution prescribed for asthma. 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.The record shows that the enrollee was registered with a patient assistance program at the time the Dupixent was prescribed. The Medicare Part D drug plan cannot cover a drug that is already covered through a patient assistance program. We determined that the plan is not required to cover the Dupixent. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Estradiol 10 microgram tablet prescribed for osteoporosis. The Part D plan denied the request stating the drug is not on the plans formulary.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. Estradiol oral tablets are listed on the plans formulary on Tier 2. However, Estradiol 5 milligram tablet is indicated for treatment of osteoporosis per Medicare approved compendia. Medicare approved compendia  do not support the use of Estradiol 10 microgram tablet for the reported condition.  A physician reviewed your appeal and determined that the plan is not required to cover Estradiol 10 microgram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Enspryng 120 milligram/milliliter solution prescribed for neuromyelitis optica. The Part D plan denied the request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.This biologic is provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary biologics are not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Oralair 300 IR (index of reactivity) sublingual tablets. The Part D plan denied the request because the plans prior authorization requirements were not met.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 Oralair has been prescribed for the treatment of allergic rhinitis due to multiple environmental allergies. However, the documentation does not indicate that the enrollee has an allergy specifically to grass pollen. Furthermore, the enrollee is more than 65-years-old. As outlined in the Medicare approved compendium, DrugDex, Orolair is indicated for the treatment of allergic rhinitis due to grass pollen in adults who are age 18 to 65 years. Therefore, the drug, as prescribed, is being used 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 prior authorization requirements are not relevant 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 Privigen 5 gram/50 milliliter intravenous solution prescribed for selective deficiency of immunoglobulin G. 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 biologic at issue is for intravenous immunoglobulin in the enrollees home. This is eligible for coverage under Part B. The plan does not offer supplemental (additional) coverage for this biologic. If the enrollee purchased biologics that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of the biologic. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armodafinil 50 milligram tablet prescribed for fatigue in multiple sclerosis. The Part D plan denied your request denied the request for coverage of the drug and denied a requested for a quantity exception of 90 tablets per 30 days.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 indicates Armodafinil is prescribed to treat fatigue in an enrollee with multiple sclerosis. However, 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 Armodafinil.