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

At issue is coverage for Aripiprazole 20 milligram tablet to treat post traumatic stress disorder and psychosis, unspecified. 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 available documentation.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. 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.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 Nubeqa 300 milligram tablet, which is not going to initially be given in combination with Docetaxel, to treat metastatic castration-sensitive prostate cancer. 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 available documentation.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The Medicare approved compendia do not contain any citations to support the use of the requested drug when not given in combination with Docetaxel for treatment of the noted condition. The submitted documentation does not include any clinically relevant, peer-reviewed medical literature from a Medicare approved journal to support this appeal. Therefore, the available documentation supports that the requested drug is not being prescribed for a 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 Cosentyx 300 milligram dose pen to treat hidradenitis suppurativa 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 available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. 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: Unfavorable

At issue is coverage for Epipen0 0.3 milligram per 00.3 milliliter solution auto injector for personal history of anaphylaxis. 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 available documentation.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 must be deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale as to why the alternative drugs on the plans formulary to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Additionally, the submitted documentation does not support that the enrollee has tried and failed all of the formulary alternative drugs. Therefore, the formulary exception requirements 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 Dexlansoprazole DR (delayed release) 60 milligram capsules to treat gastroesophageal reflux 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 available documentation.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 must be deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale as to why the alternative drugs on the plans formulary to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Additionally, the submitted documentation does not support that the enrollee has tried and failed all of the formulary alternative drugs. Therefore, the formulary exception requirements 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 coverage for Dupixent 300 milligrams per 2 milliliter pen injector to treat bullous pemphigoid. 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 available documentation.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The use of the requested drug to treat the noted condition is a non-Food and Drug Administration (FDA) use medically accepted indication as outlined in the Medicare approved compendium, Micromedex. Therefore, the drug is being prescribed for a medically accepted indication. Furthermore, the prescriber statement and the submitted documentation indicates the medical necessity for using the drug to treat the patients diagnosis. Therefore, the documentation supports an exception to the prior authorization requirement(s). 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 Cyclosporine 0.05 percent ophthalmic emulsion to treat keratoconjuctivitis 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 available documentation.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not support that all of the plans requirements for coverage have been satisfied. Furthermore, the documentation does not support the medical necessity for an exception to the plans prior authorization requirements.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 Pregabalin 25 milligram capsule to treat low back pain, other chronic pain, and myalgia. 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 available documentation.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. 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 any of these conditions. Therefore, the drug is being prescribed for non-medically accepted indications.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 Eliquis 2.5 milligram tablet to treat pulmonary embolism. 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 available documentation.Eliquis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Favorable

At issue is coverage for Imbruvica 280 milligram tablet, 60 tablets per 30 days (560 milligrams daily), to be given in combination with Rituxan and Methotrexate, to treat refractory primary central nervous system lymphoma. 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 available documentation submitted.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. As outlined in the Medicare approved compendium, the National Comprehensive Cancer Network (NCCN) guidelines, it is a Category 2A recommendation for Imbruvica to be given in combination with high-dose Methotrexate and Rituximab (Rituxan) for relapsed or refractory primary central nervous system lymphoma. Therefore, the drug is being prescribed for a medically accepted indication outlined in the NCCN guidelines. Since the drug is being used for a medically accepted indication outlined in the NCCN guidelines, an exception to the plans prior authorization requirements is supported. The requested amount of 60 tablets per 30 days (560 milligrams daily) exceeds the plans quantity limit for the drug, which is 30 tablets per 30 days. However, the NCCN guidelines indicate that the doses in the trials for the drug to treat primary central nervous system lymphoma were 560 or 840 milligrams per day. Therefore, since the requested amount of 60 tablets per 30 days (560 milligrams daily) is within the range of dosing noted in the NCCN guidelines, an exception to the plans quantity limit for the drug is also supported. A physician reviewed the appeal and determined that the requested drug at the requested amount is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Firdapse 10 milligram tablet to treat unspecified spinal muscular atrophy, congenital and developmental myasthenia, and/or congenital myasthenic syndrome with DOK7 mutation. 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 available documentation.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. 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.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 Dronabinol 2.5 milligram capsule to treat a decreased appetite in enrollee with dementia. 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 available documentation.Drugs prescribed to treat loss of appetite (anorexia) and/or weight loss that is not related to acquired immune deficiency syndrome (AIDS) wasting or cachexia due to chronic disease are excluded from the Part D coverage. Therefore, the requested drug is excluded from Medicare Part D coverage. This decision does not address the medical necessity 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 coverage for Piqray 250 milligram tablet to treat high-grade metastatic salivary gland carcinoma with PIK3CA mutation. 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 available documentation.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. 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 submitted documentation does not include any clinically relevant, peer-reviewed medical literature from a Medicare approved journal to support this appeal. It is noted that the prescriber did submit medical literature from a peer-reviewed journal, JCO Precision Oncology. However, JCO Precision Oncology is not one of the Medicare approved journals. As such, the submitted medical literature cannot be used to support this appeal. Therefore, the available documentation supports that the requested drug is not being prescribed for a 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 Welireg 40 milligram tablet to treat Von Hippel-Lindau Syndrome with renal cell carcinoma. 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 available documentation.The plan has prior authorization requirements for this drug that the enrollee must meet before coverage is provided. These requirements include a diagnosis of Von Hippel-Lindau disease, with renal cell carcinoma, and the drug Welireg used as monotherapy. The prescriber submitted a statement at appeal, and records indicate that Inlyta has been discontinued. The submitted documentation demonstrates that the member has a mutation indicating Von Hippel-Lindau renal cell carcinoma, and Welireg will be used as a monotherapy. In addition, the Medicare-approved compendia for National Comprehensive Cancer Network support using Welirig as monotherapy. Therefore, the plans prior authorization requirements have been met, and coverage for the drug is supported.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 Rinvoq ER (extended release) 30 milligram tablet to treat Sjogrens syndrome, unspecified. 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 available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. 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 coverage for Cabometyx 40 milligram tablet, to be used as second-line therapy, to treat stage 4 renal cell carcinoma. The Part D plan denied the request for coverage because the prescriber indicated that the drug was going to be given in combination with Keytruda. The use of Cabometyx in combination with Keytruda to treat renal cell carcinoma was not a medically accepted indication.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation submitted.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. At reconsideration, the prescriber statement and medical records clarify that the requested drug is not going to be given in combination with Keytruda. The newly submitted documentation indicates that Cabometyx will be given in combination with Opdivo (Nivolumab) to treat the enrollees renal cell carcinoma. The use of Cabometyx in combination with Opdivo as first-line therapy for advanced renal cell carcinoma is a medically accepted indication for the drug as outlined in the Food and Drug Administration (FDA) guidelines. However, in this case, the combination of Cabometyx and Opdivo is being given as second-line therapy. The National Comprehensive Cancer Network (NCCN) guidelines (a Medicare approved compendium) indicate that Cabometyx in combination with Opdivo can be used as subsequent therapy if prior history includes immuno-oncology therapy. The submitted medical records confirm that the enrollee has had previous immuno-oncology therapy. Therefore, the drug is being prescribed for a medically accepted indication outlined in the NCCN guidelines. In addition, since the drug is being used for a medically accepted indication outlined in the NCCN guidelines, an exception to the plans prior authorization requirements is supported. 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 Braftovi 75 milligram capsule to treat metastatic papillary thyroid cancer with BRAF mutation. 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 available documentation.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. 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 submitted documentation does not include any clinically relevant, peer-reviewed medical literature from a Medicare approved journal to support this appeal. Therefore, the available documentation supports that the requested drug is not being prescribed for a 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 Rivastigmine 4.6 milligram per 24-hour patch to treat unspecified dementia, moderate, without behavioral disturbance; psychotic disturbance; mood disturbance; anxiety; acute kidney injury; and/or intermittent memory loss. 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 available documentation.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. 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.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 Ampyra 10 milligram tablet, 60 tablets per 30 days, prescribed to improve walking in an enrollee with multiple sclerosis. The Part D plan denied the request for coverage because the following prior authorization requirement was not met: confirmation from the prescriber that enrollee had difficulty walking.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The documentation submitted at reconsideration includes a prescriber statement and medical records/progress notes that confirm that the enrollee is having difficulty walking. In addition, the previously submitted documentation supports that the plans remaining prior authorization requirements have been met, as well. Specifically, the enrollee has a diagnosis of multiple sclerosis; the drug has been prescribed by or in consultation with a neurologist; and the enrollee has an expanded disability status scale (EDSS) score less than or equal to 7. Therefore, the plans prior authorization requirements have been met and coverage for the drug is supported.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is coverage for Imatinib Mesylate 400 milligram tablet, 30 tablets per 30 days, to be given as neoadjuvant treatment for current unresectable gastrointestinal stromal tumor (GIST). The Part D plan denied the request for coverage, as the enrollees condition was negative for CD117 (KIT) mutation.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation submitted.In this case, the prescriber has noted that not enough tissue was supplied for previous testing and that they will be doing additional testing for CD117 (KIT) mutation. The National Comprehensive Cancer Network (NCCN) guidelines (a Medicare approved compendium) indicate that Imatinib Mesylate is appropriate to be given while waiting on mutation analysis, as 70 percent of GIST tumors are positive for CD117 (KIT) mutation. Since the prescriber has indicated that the previous testing was not from a good core sample and that repeat testing will be completed, the NCCN criteria are met. Imatinib Mesylate is indicated while awaiting further mutational studies. This is important in the neoadjuvant setting to get started on treatment while waiting for further studies to give best chances of resectability. Therefore, the drug is being prescribed for a medically accepted indication outlined in the NCCN guidelines. In addition, since the drug is being used for a medically accepted indication outlined in the NCCN guidelines, an exception to the plans prior authorization requirements is supported. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.