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

At issue is Lenvima 8 milligram tablets to treat advanced liver cancer, as second line therapy in an enrollee with Child Pugh Class A 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 reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates the prescriber ordered the drug at issue for the enrollees diagnosis. The Medicare approved compendia contain a citation to support the use of the drug for the noted diagnosis. As such, the submitted documentation supports the drug was prescribed for a medically accepted indication. The plan has prior authorization coverage criteria that must be met prior to approval. The enrollee satisfies the Plans coverage criteria. The submitted documentation supports the drug at issue will be used as second line therapy for progressive disease in an enrollee with Child Pugh A hepatocellular carcinoma. 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 Orencia 125 milligram per milliliter syringe. 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 diagnoses of fibromyalgia and inflammatory polyarthropathy were provided to the plan. Medical records from September 21, 2022; March 17, 2022; September 16, 2021; and April 23, 2021, were provided that all substantiated the diagnoses of fibromyalgia and inflammatory polyarthropathy. However, these 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. At reconsideration, a diagnosis of seronegative rheumatoid arthritis was given. However, no documentation was provided by the prescriber to support this diagnosis. We are not able to determine whether the requested drug was prescribed for a medically accepted indication. Therefore, the 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 coverage for Deferasirox 360 milligram tablet to treat transfusion hemosiderosis associated with the presence of sickle cell 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.At reconsideration, the prescriber has requested a peer-to-peer review for this case. However, C2C is a qualified independent review organization that has been contracted by the Center for Medicare Management (CMS) to do independent second-level appeal reviews for Part D drugs that have been denied by the Part D plans. While the Part D plans do peer-to-peer reviews, C2C has not been contracted by CMS to conduct peer-to-peer reviews. Therefore, a peer-to-peer review is not possible at this level and the case will be reviewed, as contracted. The plan has prior authorization requirements for this drug that must be met before coverage can be approved. The submitted documentation does not support that all of the plans requirements for coverage have been met. The plans prior authorization requirements indicate that the enrollees estimated glomerular filtration rate (eGFR) must be greater than or equal to 40 mL/min/1.73m2. The submitted laboratory results show that the enrollees eGFR is 26 mL/min/1.73m2. As such, this requirement has 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: Unfavorable

At issue is coverage for Taltz 80 milligram per milliliter auto-injector (3-pack) to treat psoriatic arthritis. 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 plan has prior authorization requirements for this drug that must be met before coverage can be approved. The submitted documentation does not support that all of the plans requirements for coverage have 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: Unfavorable

At issue is a request for coverage of Methotrexate 2.5 milligram tablet to treat acute lymphoblastic leukemia. The Part D plan denied the request for coverage. 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. Coverage is available under Medicare Part B for drugs taken orally during cancer chemotherapy if they have the same active ingredients (or are pro-drugs) and are used for the same cancer as chemotherapy drugs that would be covered if they were not self-administered. (i.e., intravenous drugs). As such, coverage of this drug would be available under Medicare Part B. Drugs that are eligible for Part B coverage are excluded from Part D coverage by Medicare law. This decision does not refer to the medical necessity of the requested drug. It only establishes that payment cannot be made under the Part D benefit. Please submit the request for coverage through Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nubeqa 300 milligram tablet, to be used in combination with Eligard, to treat metastatic hormone-sensitive prostate cancer. 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 Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. The prescriber did not submit any clinically relevant, peer-reviewed medical literature from a Medicare approved journal to support this appeal. As such, the submitted documentation supports that the requested drug is being prescribed for a non-medically accepted indication as defined by Medicare.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 coverage for Onureg 300 milligram tablet, 14 tablets per 28 days, to treat acute myeloid leukemia. The Part D plan denied the request for coverage because the documentation indicated the enrollee was going to be getting consolidation therapy and then proceeding to stem cell transplant. 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 that must be met before coverage can be approved. The plans prior authorization requirements are that the enrollee has achieved first complete remission or complete remission with incomplete blood count recovery following intensive induction chemotherapy and that the enrollee is not able to complete intensive curative therapy. The submitted medical records validate that the enrollees acute myeloid leukemia has achieved remission after induction chemotherapy. Furthermore, the documentation submitted at reconsideration clarifies that the enrollee developed a bladder perforation and as such, is no longer a candidate for transplant or consolidation therapy. Therefore, the enrollee is not able to complete intensive curative therapy.As such, the documentation now confirms that the plans prior authorization requirements for this drug have been satisfied and coverage for the drug is supported. Furthermore, the amount requested does not exceed the plans quantity limit for the drug.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 coverage for Repatha Sureclick 140 milligram per milliliter solution auto-injector to treat hyperlipidemia in an enrollee with atherosclerotic cardiovascular 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. To grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed, or deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale with supporting documentation, as requested, to validate why the formulary alternative drug listed by the plan 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: Unfavorable

At issue is coverage for Intrarosa 6.5 milligram vaginal insert. The Part D plan denied the request for coverage because the drug was being prescribed for a non-medically accepted indication. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.The progress notes submitted to the plan indicate the requested drug was prescribed to treat postmenopausal vaginal dryness. However, 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. At reconsideration, the submitted progress notes now also include a diagnosis of postmenopausal dyspareunia (painful sexual intercourse). However, drugs when used for the treatment of sexual dysfunction are excluded from coverage under Medicare Part D. As such, the requested drug is excluded from Part D coverage.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 Jakafi 5 milligram tablets to treat VEXAS syndrome. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates the prescriber ordered the drug at issue for the enrollees diagnosis. The prescriber submitted a Medicare approved journal article to support the use of the drug for this condition. The Medicare approved journal, Blood, contains an article titled, 'Ruxolitinib is More Effective Than Other JAK Inhibitors to Treat VEXAS Syndrome'. The article indicates that the drug at issue was effective in those patients that had no evidence of a current bone marrow disorder, and had been on steroids. The enrollee fits the criteria of the study. As such, the submitted documentation supports the drug was prescribed for a medically accepted indication. The plan has prior authorization coverage criteria that must be met prior to approval. The enrollee satisfies the Plans coverage criteria. The criteria indicates the enrollee must have a Food and Drug Administration approved indication. The Medicare approved compendia contain a citation to support the use of the drug for the enrollees noted diagnosis. Therefore, an exception to the plans coverage criteria is medically necessary. 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 Vyndamax 61 milligram capsule to treat cardiac amyloidosis. 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 approved. The submitted documentation does not satisfy all of 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 Orladeyo 110 milligram capsule to treat acquired angioedema. 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 Sodium Chloride 0.9 percent solution prescribed for the treatment of multiple sclerosis. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the requested drug does not meet the definition of a Part D drug. Based on the information provided, we determined the drug may be eligible for coverage under Part B under Medicare rules. 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 Neupro 4 milligram per 24-hour patch to treat Parkinson's 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 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 and failed, or deemed contraindicated. In this case, the documentation does not include valid patient-specific reason(s) as to why the formulary alternatives required by the plan 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 coverage for Revlimid 5 milligram capsule to treat high-risk myelodysplastic syndrome in an enrollee who is not transfusion-dependent. 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. Please note that in the reconsideration appeal form relevant medical records were requested. No medical records were received.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. The prescriber did not submit any clinically relevant, peer-reviewed medical literature from a peer-reviewed Medicare approved journal to support this appeal. As such, the submitted documentation supports that the requested drug is being prescribed for a non-medically accepted indication as defined by Medicare.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 coverage for Colchicine 0.6 milligram tablet to treat calcium pyrophosphate arthritis. 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 use of the requested drug to treat the noted 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 this condition. Therefore, the drug is being prescribed for a non-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: Favorable

At issue is Ultomiris 1100 milligram per 11 milliliter solution to treat myasthenia gravis with (acute) exacerbation. 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 drug at issue is not on the plans formulary. The prescriber provided patient-specific clinical rationale supported by documentation indicating why the 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 medically necessary.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 Kevzara 200 milligram per 1.14 milliliter pen injector to treat giant cell arteritis. 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 Belbuca 75 microgram buccal film to treat severe pain due to cancer. 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 and failed, or deemed contraindicated. In this case, the documentation does not support why the formulary alternatives required by the plan 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 a tiering exception request for Rasagiline Mesylate 1 milligram tablet to treat Parkinson's 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 reviewed all documentation submitted, including the case file from the plan and any information submitted at the reconsideration level.Rasagiline Mesylate 1 milligram tablet is a generic drug on Tier 3 of the plans formulary. There are no 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 a tiering exception request for Ursodiol 250 milligram tablet prescribed for the prevention of choledocholithiasis. 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.Ursodiol 250 milligram tablet is a generic drug on Tier 2 of the plans formulary. There are no 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 coverage for Loperamide Hydrochloride 2 milligram tablet. 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 available over the counter without a prescription. Nonprescription drugs, even when a prescription has been written, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.This decision does not address the medical necessity of the requested 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 tiering exception request for Stelara 90 milligram per milliliter solution prefilled syringe to treat Crohn's 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 reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.This biologic 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. The drug will continue to be covered at the current copay.