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

At issue is a tiering exception request for Invokana 100-milligram tablets to treat type 2 diabetes mellitus with unspecified complications. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Invokana is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same diagnosis. Therefore, this drug is not eligible for a tiering exception.A physician reviewer determined that the tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nuplazid 10-milligram tablets to treat psychotic episodes and hallucination due to Lewy body dementia. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Upon reconsideration, the prescribers appeal letter dated November 8, 2021, indicates the enrollee has a diagnosis of Parkinsons disease. However, the prescriber did not provide medical records or progress notes to support the diagnosis of Parkinsons disease.The use of the requested drug to treat the provided diagnosis of psychotic episodes and hallucination due to Lewy body dementia is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

Excluded Drug/Use=Not covered by Part DAt issue is Diethylpropion 25-milligram tablets to treat abnormal weight gain. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed to treat weight gain (promote weight loss) are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rexulti 0.25-milligram tablets to treat dysthymic disorder. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Upon redetermination, the plan denied the appeal request stating the plans prior authorization was not met. However, the use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Buprenorphine 5-microgram per hour weekly transdermal patches, 4 patches per 28 days, to treat chronic pain due to postherpetic neuralgia. The Part D plan denied the request for coverage because the drug was not on the formulary and the documentation did not support that the enrollee tried and failed, or had a contraindication to, the required formulary alternative drug, Tramadol ER. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.At reconsideration, the prescriber has submitted a prescriber statement and medical records to confirm the enrollee has tried many alternative medications to treat the chronic postherpetic pain including Tramadol ER, Tramadol IR, Norco, Percocet, OxyContin IR, Nucynta ER, many over-the-counter medications, and non-narcotic pain medications specific for 'nerve pain' such as Lyrica, Gabapentin, and Cymbalta. Therefore, the documentation submitted at reconsideration supports a formulary exception.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 Modafinil 200-milligram tablets, 60 tablets per 30 days. The Part D plan denied the request for coverage because the drug was being prescribed for a non-medically accepted indication. Additionally, the amount requested exceeded the plans quantity limit of 30 tablets per 30 days.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that Modafinil has been prescribed for the treatment of extreme fatigue secondary to myasthenia gravis. However, the use of the requested drug to treat this condition is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of 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, the plans quantity limit for the drug 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 Xadago 50-milligram tablets to treat Parkinsons disease. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The requested drug is not on the plans formulary. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs required by the plan, must have been tried, failed, or deemed contraindicated. In this case, the prescriber has not addressed the formulary alternatives included in the plan to treat the enrollees condition and provided patient specific clinical rationale as to why each formulary alternative would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Therefore, the formulary exception criteria have not been met.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Glatiramer Acetate 40-milligram per milliliter prefilled subcutaneous injection syringe, 12 syringes per 28 days. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. During the review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to clarify the condition being treated and to validate the enrollee has satisfied the plans coverage requirements for the requested drug. We received additional documentation and included it in the review.The submitted documentation indicates that Glatiramer Acetate has been prescribed for the treatment of relapsing multiple sclerosis. This is a medically accepted indication for the use of the drug, as outlined in the Medicare approved compendia. The documentation supports that the plans prior authorization requirements for coverage of Glatiramer Acetate have been met as the drug is being used a medically accepted indication, the drug has been prescribed by a neurologist, and the prescriber has validated that there will be no concurrent use with other disease-modifying agents used for multiple sclerosis. The plans quantity limit for the drug is 12 syringes (12-milliliters) per 28 days, which is what has been requested. Therefore, the documentation validates that the drug is being used for a medically accepted indication, the plans prior authorization requirements have been satisfied, and the quantity limit has not been exceeded. As such, payment 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 Diazepam 5-milligram tablets to treat chronic interstitial cystitis. The Part D plan denied the request for coverage because the plans concurrent opioid benzodiazepine drug utilization requirement was not met, as the prescriber did not validate it was appropriate for the enrollee to take an opioid along with a benzodiazepine drug.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat chronic interstitial cystitis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. Since the drug is not eligible for coverage, the plans concurrent opioid benzodiazepine drug utilization requirement is not relevant to this review.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 Promethazine Hydrochloride 25-milligram tablets to treat nausea and vomiting due to chemotherapy. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Xifaxan 550-milligram tablets to treat irritable bowel syndrome with chronic diarrhea. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.This drug is being provided by the plan at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules. A physician reviewer determined that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dronabinol 10-milligram capsules to treat gastroparesis, unintentional weight loss, failure to thrive, refractory nausea and vomiting. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug(s) is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Xifaxan 550-milligram tablets to treat chronic encephalopathy from hepatic insufficiency. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.We requested additional information from the prescriber. Specifically, we requested clarification of the diagnosis related to the requested drug. We also requested supporting medical records indicating that the enrollee has satisfied the plans prior authorization coverage criteria. We received additional documentation and included it in our review.Upon redetermination, the plan denied the appeal stating that the provided diagnosis (medication-induced constipation) was a non-medically accepted indication. On reconsideration, the prescriber indicates the continuation of therapy with Xifaxan for the treatment of hepatic encephalopathy. The diagnosis of hepatic encephalopathy is a medically accepted indication per the Medicare approved compendia. The documentation satisfies the plans coverage criteria. The enrollee has been taking the requested drug since 2014. The documentation also notes that Lactulose was discontinued due to high ammonia levels.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 Flovent HFA 110-microgram per actuation inhaler prescribed for an unknown condition. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. We reviewed all documentation submitted.The requested drug is not on the plans formulary. Additionally, the available documentation does not include any indication of the enrollees condition that is being treated with the requested drug. During this review, a request was submitted to the prescriber to provide a diagnosis and supporting medical records and to address the alternative medications included in the plans formulary to treat the enrollees condition. A reply from the prescriber was not received. Without a diagnosis, it cannot be established that the requested drug is being prescribed for a medically accepted indication. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Livalo 2-milligram tablet to treat mixed hyperlipidemia. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.We requested additional information from the prescriber. The prescriber has not provided patient specific clinical rationale, supported by documentation, as to why all formulary alternatives required by the plan would likely not be as effective as the requested drug for this diagnosis, and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not medically necessary. 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 Otezla 28 day starter pack to treat psoriasis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The requested drug is not on the plans formulary. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the documentation does not support why alternative drugs provided on the plans formulary list would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Carisprodol 350-milligram tablet. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.A request was submitted to the prescriber to provide a diagnosis, to clarify the medical history, and to provide supporting medical records.  A reply from the prescriber was not received. Without a diagnosis, it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. 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: Unfavorable

At issue is a tiering exception request for Lamivudine 300-milligram tablets to treat human immunodeficiency virus (HIV) 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 your case file carefully. We reviewed all documentation submitted. During this review, we requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support all lower-tiered drugs to treat the enrollees condition were tried and failed or were contraindicated. The prescriber did not respond to the request. Lamivudine is a generic drug on Tier 4 of the plans formulary. The prescriber has not addressed all drugs of the same type on the lower tiers of the plans formulary to treat the enrollees condition. The prescriber has not provided patient specific clinical rationale as to why each lower-tiered drug has been tried and failed, or is contraindicated. Therefore, the tiering exception criteria have not been met.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 Welchol 625-millligram tablets. 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 reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The submitted medical records indicate that Welchol has been prescribed for the treatment of mixed hyperlipidemia and intestinal malabsorption. However, the noted conditions are off-label uses for the requested drug. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these conditions. Therefore, the drug is being prescribed for non-medically accepted indications 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 Megestrol 625-milligrams/5-milliliter suspension to treat unintentional weight loss. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed to treat anorexia and/or weight loss, unrelated to AIDS wasting or cachexia due to certain chronic diseases, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage. Of note, the appellant requested a tiering exception. As the drug is excluded from coverage for the prescribed diagnosis, a tiering exception cannot be granted.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300-milligrams per 2-milliliters solution prefilled syringe to treat bullous pemphigoid. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this diagnosis. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Estradiol 1-milligram tablets to treat vasomotor symptoms of menopause. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The prescriber indicates that the enrollee has not tried and failed all available formulary drugs for the same diagnosis or condition. The submitted documentation does not satisfy the plans coverage criteria.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Loteprednol 0.5-percent ophthalmic gel to treat bilateral keratoconjunctivitis sicca. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support all formulary alternatives were tried and failed or were contraindicated. We received additional documentation and included it in the review.The requested drug is not on the plans formulary. In order to grant an exception for a drug not on the plans formulary, all alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the prescriber has not addressed all formulary alternatives included in the plan to treat the enrollees condition and provided patient specific clinical rationale as to why each formulary alternative would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Therefore, the formulary exception criteria have not been met.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.