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

At issue is Pomalyst 2 milligrams prescribed daily for high risk immunoglobulin A kappa multiple myeloma. The Part D plan denied the drug because medical necessity was not shown. The plan requires prior approval before covering some drugs. If prior approval is not obtained, the plan may not cover the drug. We received a reconsideration 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.Pomalyst is being requested for multiple myeloma. A plan must grant an exception to prior approval rules if it determines that the drug is medically necessary, consistent with the prescriber's statement. The plan formulary states prior approval rules only apply to new starts. The prescribers statement shows the enrollee has previously been on this drug since 2019. The statement also shows that Lenalidomide and a proteasome inhibitor were trialed with disease progression.In this instance, the QIC has determined that coverage can be allowed for the Pomalyst. The Part D plan covers drugs for a medically accepted indication and there is an exception to prior approval rules. The documentation provided shows the enrollee has satisfied the plan's prior approval coverage criteria. Therefore, the plan is required to allow coverage for the Pomalyst.
Appeal type: Prescription Drug
Decision: Favorable

You requested Northera 300 milligrams prescribed as directed for neurogenic orthostatic hypotension. The Part D plan denied your request because it does not meet the criteria of a medically accepted indication. We received an expedited reconsideration request. We performed 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. Your medical records show your doctor prescribed Northera 300 milligrams for neurogenic orthostatic hypotension. The Medicare approved compendia support the use of this drug for your condition. Therefore, the drug can be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is required to cover Northera 300 milligrams daily because it was prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Aimovig, 70 milligrams per milliliter auto injector, one auto injector per 28 days, which has been prescribed for the preventative treatment of migraine headache. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received an expedited reconsideration request.We performed 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. The medical records show your doctor prescribed Aimovig to treat your migraine headaches. The Medicare approved compendia do support the use of this drug for your condition. Your Part D drug plan requires that certain prior authorization requirements be met before they will cover the Aimovig. To meet these requirements, your doctor must confirm the following: 1) you have four or more migraine headache days per month before starting migraine-preventative medication, 2) you will not be taking the requested drug in combination with the medications Ajovy or Emgality, and 3) you have tried and failed, or have a medical reason not to try at least two different drugs that are from at least two different medication classes that are used to prevent migraines. The documentation provided from your physician supports that that you have had four or more migraine headache days per month before starting migraine-preventative medication. Additionally, the medical records show that the Aimovig is not being used in combination with either Ajovy or Emgality. Also, your medical records show that you have tried and had inadequate responses to at least two other drugs from two different medication classes that are used to prevent migraines. These drugs include Fioricet and Imitrex. Therefore, your medical records support that the plans prior authorization requirements have been satisfied.A physician reviewed your appeal and determined that the plan is required to cover the Aimovig.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Tacrolimus 1 milligram prescribed for after care following a kidney transplant that was performed on October 9, 2017. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received an expedited reconsideration request. We performed 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 also researched Medicare systems and reviewed the enrollment data available.We determined that the drug is not eligible for Part B coverage. The record shows the enrollee underwent a kidney transplant on October 9, 2017. A drug prescribed for a Part D eligible individual cannot be considered a covered Part D drug if payment for the drug is available under Medicare Part A or B for that individual. Medicare systems show that the enrollee was not covered under Medicare Part A/ B until April 1, 2018. Therefore, the drug can be considered for payment under the Part D benefit.The records show the doctor prescribed Tacrolimus for post-kidney transplant treatment. The drug requested is on the plans formulary and is medically indicated for a post-kidney transplant enrollee per Medicare approved compendia. A physician reviewed your appeal and determined that the plan is required to cover Tacrolimus
Appeal type: Prescription Drug
Decision: Favorable

At issue is Mycophenolate mofetil 250 milligrams prescribed four capsules twice a day for status-post pancreas transplant. The Part D plan denied the request because Mycophenolate mofetil is not Food and Drug Administration labeled or the Centers for Medicare and Medicaid Services compendia did not support the medically accepted indication for the enrollees condition. We received a request to reconsider the appeal. 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. According to the medical record, the pancreas transplant was performed on March 31, 2015, while the enrollees Medicare eligibility started on March 1, 2019. The pancreas transplant was not covered by Medicare A or B.The medical record also shows Mycophenolate mofetil has been prescribed since the pancreas transplant. Mycophenolate Mofetil is on the plans formulary. Detailed review of the CMS approved compendium, Micromedex, reveals a positive citation regarding use of this drug after pancreas transplant. Patients treated with mycophenolate mofetil after pancreatic transplantation experienced fewer episodes of acute and steroid-resistant rejection compared with patients receiving azathioprine for posttransplant rejection prophylaxis. Per the Center for Medicare and Medicaid Services, this positive citation establishes that this drug is being used for a medically accepted indication.A physician reviewed your appeal and determined that the plan is required to cover or allow payment under your Medicare Part D benefit for Mycophenolate mofetil 250 milligrams.
Appeal type: Prescription Drug
Decision: Favorable

You requested Testosterone 1.62% gel pump prescribed three times daily for hypogonadism. The Part D plan denied your request because the quantity limit of 150 grams per 30 days was exceeded. We received a reconsideration request. We performed 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 show you prescribed Testosterone 1.62% gel pump to treat the enrollees hypogonadism. The prescriber statement indicates that the prescription for 450 grams of Testosterone 1.62% gel is a 90 day supply, and not a 30 day supply. Therefore, the quantity limits have not been exceeded. As such, the plan will cover the requested quantity of 450 grams of Testosterone 1.62% gel per 90 days.A physician reviewed your appeal and determined that the plan will cover Testosterone 1.62% gel pump.
Appeal type: Prescription Drug
Decision: Favorable

You requested coverage for Diclofenac Sodium Gel 3 percent prescribed daily for chronic pain syndrome. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you were prescribed Diclofenac Sodium Gel 3 percent for chronic pain syndrome related to osteoarthritis and pain in multiple joints. In review of the Medicare approved compendia, osteoarthritis is a medically accepted indication for Diclofenac Sodium Gel. Therefore, it does meet the definition of a Part D drug. The plan is required to cover the Diclofenac Sodium Gel at issue.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Diphenoxylate HCL/Atropine Sulfate 2.5 milligrams/0.025 milligrams prescribed every eight hours as needed for diarrhea. The Part D Plan missed the request for a tiering exception and processed the case as a formulary exception. We received an expedited auto-forwarded reconsideration request from the plan. We performed 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 a prescriber statement. We received the documentation and included it in our review.Your physician submitted a supporting statement and medical records. The medical records show the physician had prescribed the drug to treat your diarrhea from chemotherapy medication. The Medicare approved compendia support the use of this drug for this condition. Diphenoxylate HCL/Atropine Sulfate is a generic drug on Tier 4 of the plans formulary. The prescriber statement shows you have previously tried Loperamide HCL and it was ineffective to treat your condition. The plans formulary includes a lower tier generic alternative of the same type to treat your condition, Loperamide HCL, which your doctor has stated does not work. All alternatives on a lower cost-sharing level have been tried and failed. A physician reviewed your appeal and determined that the plan is required to cover the drug at the lower cost-sharing level.
Appeal type: Prescription Drug
Decision: Favorable

You requested Ferriprox prescribed twice daily for hemochromatosis due to repeated red blood cell transfusions. The Part D plan denied your request because the medication is not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed 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 show you prescribed Ferriprox to treat the enrollees hemochromatosis due to repeated red blood cell transfusions. The Medicare approved compendia do support the use of this drug for this condition. There are no prior authorization criteria for Ferriprox to treat hemochromatosis due to repeated red blood cell transfusions.A physician reviewed your appeal and determined that the plan can cover Ferriprox.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Myfortic 180 milligrams to treat kidney and liver transplants. The Part D Plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received an expedited reconsideration request. We performed 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 also researched Medicare systems and reviewed the enrollment data available.Based on the information provided, we determined the drug would be eligible for coverage under Part D. There is no information in the Medicare Database that indicates this enrollee had a covered transplant paid for by Medicare. This drug is on the plans formulary and is being used for a medically accepted indication.A physician reviewed your appeal and determined that the requested drug should be covered by your Part D plan.
Appeal type: Prescription Drug
Decision: Favorable

You requested Austedo 6 milligram tablets prescribed daily for tardive dyskinesia. The Part D plan denied your request because the prior authorization criteria were not met. Specifically, the documentation did not specify if the enrollee had untreated or inadequately treated depression. We received an expedited reconsideration request. We performed 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 the prescriber to send us medical records and a prescriber statement to show the need for this medication. We received the documentation and included it in our review.The medical records show the doctor prescribed Austedo to treat tardive dyskinesia. The Medicare approved compendium does support the use of this drug for this condition. The medical records also show the enrollee has a history of treatment with Zyprexa, which is a dopamine receptor blocking agent. The enrollee has involuntary choreiform movements and moderate tardive dyskinesia, as evidenced by a score of 3 on item 8 of the Abnormal Involuntary Movement Scale. The medical records do not show that the enrollee has hepatic impairment. The medical records do not show that the enrollee is currently using, or has recently used, Monoamine Oxidase Inhibitors, Resperine, or Tetrabenazine. The prescriber statement indicates the beneficiary does not have untreated or inadequately treated depression. The physician progress note dated February 2, 2021, indicates the enrollee is treated for bipolar II disorder with Lamictal. The physician states the enrollees mood is stable and the enrollee self-reports mood as good. The physician states the enrollee continues with regular daily activities, has fairly good energy, stable appetite, and denies suicidal ideation. The documentation provided shows the enrollee has satisfied the plan's coverage criteria.We determined that the plan is required to cover the Austedo. The Medicare rules above have been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Latuda 20 mg prescribed daily for bipolar disorder. The Part D plan denied your request because the documentation did not support a medically accepted indication for the drug. We received an expedited reconsideration request. We performed 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 show Latuda was prescribed to treat Bipolar disorder. The Medicare approved compendia do support the use of Latuda for your condition. The Plans formulary requires that the enrollee try Quetiapine prior to coverage of Latuda for the diagnosis of Bipolar disorder. The documentation shows that the enrollee tried and failed Quetiapine. A physician reviewed your appeal and determined that the plan can cover Latuda.
Appeal type: Prescription Drug
Decision: Favorable

You requested coverage for Oxiconazole Nitrate topical cream prescribed twice daily for tinea unguium and onychomycosis. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you were prescribed Oxiconazole Nitrate for tinea unguium and onychomycosis. In review of the Medicare approved compendia, tinea unguium and onychomycosis affect are not medically accepted indications for Oxiconazole Nitrate. However, the medical records submitted indicate a diagnosis of tinea pedis of the bilateral feet. This is a medically accepted indication. Therefore, it does meet the definition of a Part D drug. The plan will cover the drug at issue.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Eszopiclone 1 milligram prescribed daily for insomnia. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an expedited reconsideration request. We performed 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 record includes a supporting statement and medical records. The medical records show the physician had prescribed Eszopiclone to treat insomnia. The Medicare approved compendium supports the use of the requested drug for this condition. In addition, the plans formulary includes Escopiclone 1 milligram as a Tier 1 drug. Therefore, there is no need for an off-formulary exception.A physician reviewed your appeal and determined that the plan is required to cover Eszopiclone.
Appeal type: Prescription Drug
Decision: Favorable

You requested coverage for Nuedexta (dextromethorphan 20 milligrams with quinidine 10 milligrams) capsules prescribed twice daily for pseudobulbar affect. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received a reconsideration request. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows you were prescribed Nuedexta for pseudobulbar affect. In review of the Medicare approved compendia, pseudobulbar affect is a medically accepted indication for Nuedexta. Therefore, it does meet the definition of a Part D drug. The plan will cover the drug at issue.
Appeal type: Prescription Drug
Decision: Favorable

You requested Xeljanz 11 milligram tablet prescribed daily for rheumatoid arthritis. The Part D plan denied your request because the prior authorization criteria were not met. Specifically, the prescriber stated the drug would be used concurrently with another biologic therapy. We received an expedited reconsideration request. We performed 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 show the doctor prescribed Xeljanz to treat rheumatoid arthritis. The Medicare approved compendium does support the use of this drug for this condition. The physician ordered Xeljanz after a trial of Orencia. The two drugs are not being ordered to use at the same time. Multiple other drugs to treat the condition have been tried. The documentation provided shows the enrollee has satisfied the plan's coverage criteria. Therefore, your medical records support that the plans prior authorization requirements have been satisfied.We determined that the plan is required to cover the Xeljanz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Buprenorphine HCL 8 milligram sublingual tablets prescribed for chronic pain. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed 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. Your medical records show your doctor prescribed the requested drug to treat chronic pain. The use of the requested drug to treat chronic pain syndrome 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 the enrollees condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Favorable

You requested Rinvoq ER 15 milligram capsules prescribed daily for adult-onset Stills disease. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited reconsideration request. We performed 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 show Rinvoq ER was prescribed to treat adult-onset Stills disease. The enrollee has inflammatory arthritis since adult onset of Stills disease and treatment has included Methotrexate. The Food and Drug Administration and the Plans formulary cover Rinvoq for the treatment of adults with moderately to severe rheumatoid arthritis who have had an inadequate response or intolerance to Methotrexate. A physician reviewed your appeal and determined that the plan is required to cover Rinvoq.