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

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for the Shingrix vaccine purchased January 20, 2020. ThePlan did not grant this request. We received this case to conduct an independent review.Medicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. In this case,documentation in the record shows that the enrollee was in the deductible stage when the Shingrix vaccinewas purchased on January 20, 2020. During the deductible stage, the Plan requires that the enrollee pay thefull cost of Tier 3, Tier 4 and Tier 5 drugs purchased in 2020 before the Plan would pay a share of the cost.The Shingrix vaccine is on the Plan's 2020 formulary and classified as a Tier 3 drug. The Plan provideddocumentation showing that this claim was covered by the Plan at the time of purchase, and that the fullcost of the purchase in dispute was applied to the required deductible amount.The case record indicates that the Plan provided coverage in accordance with the Part D Plan contract.Therefore, our decision is the Plan is not required to provide reimbursement for the Shingrix vaccinepurchased January 20, 2020.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Testosterone Cypionate. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for a tiering exception for Testosterone Cypionate.Testosterone Cypionate is requested to treat your condition. The requested drug is on Tier 3 of the Plan's formulary. There are no available lower tier drugs on the Plan's formulary to treat your condition. Therefore, the requested drug is not eligible for a tiering exception. Our Physician Reviewer's opinion is that tiering exception criteria are not met.Medicare rules permit a Plan to grant an exception to its tiering structure so long as there is a drug of the same type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) in a lower cost-sharing tier approved for treating the same condition that the higher cost-sharing tiered drug is being used to treat. Our Physician Reviewer's opinion is that tiering exception criteria are not met because there are no lower cost-sharing tiered drugs of the same type for treating the enrollee's condition. Therefore, our decision is the Plan is not required to provide a tiering exception for Testosterone Cypionate.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for Cyanocobalamin purchased August 19, 2019. The Plan did not grant this request. We received this case to conduct an independent review.Medicare law excludes certain drugs from Part D coverage. Cyanocobalamin is one of those excluded drugs because it is a prescription vitamin and mineral product. The record submitted by the Plan does not indicate that they provide supplemental coverage for Cyanocobalamin. Therefore, the Plan is not required to cover or provide reimbursement for Cyanocobalamin purchased August 19, 2019. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Otezla. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Otezla 30mg Tablet. Otezla 30mg Tablet is requested for treatment of moderate to severe psoriasis in this 79-year-old woman, which has not responded to topical therapy. The plan's denial letter states that Humira, Enbrel, Skyrizi, Triamcinolone dental paste, and Cosentyx are on their formulary. The prescriber states that the enrollee has a history of lung and brain cancer, as well as a history of chronic obstructive pulmonary disease with frequent COPD exacerbations. The medical records confirm that this elderly woman has a history of COPD, lung cancer and brain cancer. The enrollee's medication list includes, but is not limited to Budesonide, Albuterol, Amlodipine, and levetiracetam. The prescriber has provided a sufficiently strong statement as to why the alternatives required by the Plan would likely not be as effective as the requested drug for the enrollee, and/or would likely cause adverse reaction(s) or other harm to this elderly enrollee. Therefore, an exception to the Plan's coverage criteria is medically necessary. Our Physician Reviewer's opinion is that formulary exception criteria are met.A Plan must grant an exception for a drug that is not on its formulary if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on a review of the available documentation, our Physician Reviewer's opinion is that formulary exception criteria are met. Therefore, the Plan is required to cover Otezla.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Fluvastatin Sodium 20 mg capsule. The Plan did not grant this request. Wereceived this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Fluvastatin Sodium 20 mg capsule.Fluvastatin Sodium 20 mg capsule is requested use in this enrollee who the prescriber has indicated has ahigh risk of atherosclerotic cardiovascular disease, based on family history, coronary calcium on CT scanand blood work. It was noted at the time of the initial request that the enrollee had tried Rosuvastatin andPravastatin. The plan indicates that Simvastatin, Atorvastatin and Lovastatin are on their formulary. Theprescriber has indicated that the enrollee had adverse side effects to Rosuvastatin and Pravastatin;additionally, the prescriber states that the enrollee has had adverse effects with Simvastatin andAtorvastatin as well. The prescriber has provided a sufficiently strong statement supported by medicalreferences as to why the requested drug is the best option for this enrollee. The prescriber has indicatedwhy all alternatives required by the Plan would likely not be as effective as the requested drug for theenrollee, and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, anexception to the Plan's coverage criteria is medically necessary. Our Physician Reviewer's opinion is thatformulary exception criteria are met,Of note, many experts state that Pravastatin, pitavastatin, and fluvastatin appear to have much lessassociated muscle toxicity than other statins, and that a trial of one of these statins should be considered inpatients with a history of statin myopathy.A Plan must grant an exception for a drug that is not on its formulary if it determines that the requesteddrug is medically necessary, consistent with the prescriber's statement. Based on a review of the availabledocumentation, our Physician Reviewer's opinion is that formulary exception criteria are met. Therefore,the Plan is required to cover Fluvastatin Sodium.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Tobramycin nebulizer solution. The Plan did not grant this request. Wereceived this case to conduct an independent review.Medicare law specifically excludes coverage for any drug for which payment would be available under PartA or Part B of Medicare for that individual. Medicare Part B may pay for supplies necessary for theeffective use of durable medical equipment, including drugs and biologicals which must be put directly intothe equipment in order to achieve the therapeutic benefit of the durable medical equipment. Medicare PartB local policy states that a small volume nebulizer and related compressor are covered when medicallynecessary to administer Tobramycin nebulizer solution for the management of cystic fibrosis orbronchiectasis.In this case, the record shows that Tobramycin nebulizer solution is administered through a nebulizer in thehome for a diagnosis of ICD-10 J47.9 (Bronchiectasis, uncomplicated) and B96.5 (Pseudomonas(aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere). There is no indicationthat it is not administered through a small volume nebulizer. It appears that this medication is eligible forcoverage under Part B rather than Part D. Drugs which are eligible for coverage under Part B are excludedfrom Part D coverage by Medicare law. Therefore, it is our decision that the Part D Plan is not required tocover Tobramycin nebulizer solution.This decision does not concern the medical necessity or appropriateness of the requested drug. It onlyestablishes if payment can be made under the Medicare Part D benefit.You may wish to submit this request to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Qnasl 80 mcg nasal spray. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Qnasl 80 mcg nasal spray. The drug is requested to treat the enrollee's condition. A request for prescriber statement was sent and not returned. You have not indicated why all alternatives required by the Plan would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exception criteria are not met.A Plan must grant an exception for a drug that is not on its formulary if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on a review of the available documentation, our Physician Reviewer's opinion is that formulary exception criteria are not met. Therefore, the Plan is not required to cover Qnasl 80 mcg nasal spray.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Lyrica, 200 mg capsule. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Lyrica, 200 mg capsule.The drug is requested to treat [the enrollee's condition. A request for prescriber statement was sent and not returned. The prescriber has not indicated why all alternatives required by the Plan would likely not be as effective for the enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is not supported. Our Physician Reviewer's opinion is that formulary exception criteria are not met.A Plan must grant an exception for a drug that is not on its formulary if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on a review of the available documentation, our Physician Reviewer's opinion is that formulary exception criteria are not met. Therefore, the Plan is not required to cover Lyrica, 200 mg capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Getryl. The Plan did not grant this request. We received this case to conduct anindependent review.Getryl is not covered by Medicare because it was purchased outside the United States. Therefore, ourdecision is that the Part D Plan is not required to pay for Getryl.This decision does not concern the medical appropriateness of the requested drug. It only establishes ifpayment can be made under the Medicare Part D benefit
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Advair Diskus. The Plan did not grant this request.We received this case to conduct an independent review.Medicare rules do not require the Part D plan to grant a tiering exception for a brand or biologic drug of thesame type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) ifthe lower tier(s) on the formulary only contain(s) generic alternative drugs. Advair Diskus is a Tier 3 branddrug. The lower cost-sharing tier(s) only contain(s) generic alternative drugs. Therefore, our decision is thePlan is not required to provide a tiering exception for Advair Diskus.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Lidocaine 5% Patch. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Lidocaine 5% patch. The drug is requested to treat hip pain due to osteoarthritis. For coverage under the prescription drug benefit, Medicare requires that the drug prescribed be used for a medically accepted indication. Our Physician Reviewer found that the Medicare-approved resources do contain citations to support the use of the requested drug for treatment of the noted condition - Krebs EE, Gravely A, Nugent S, et al: Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial. JAMA 2018; 319(9):872-882. Therefore, the requested drug is being prescribed for a medically accepted indication. The enrollee satisfies the Plan's coverage criteria. Our Physician Reviewer's opinion is that prior authorization criteria are met.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. A medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia. Our Physician Reviewer reviewed this file and determined that there are citations in the Medicare approved compendia that support the use of Lidocaine 5% Patch for the diagnosed condition. As a result, Lidocaine 5% Patch is being prescribed for a medically accepted indication as defined by Medicare law. Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. Based on the available documentation, our Physician Reviewer's opinion is that prior approval criteria are met. Therefore, our decision is the Plan is required to cover Lidocaine 5% Patch.
Appeal type: Prescription Drug
Decision: Partially Favorable

You asked the Plan to cover Diphenhydramine HCl 12.5 mg/5 ml oral elixir. The Plan did not grant this request. We received this case to conduct an independent review.Diphenhydramine HClYou asked the Plan to cover Diphenhydramine HCl 12.5 mg/5 ml oral elixir.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Diphenhydramine HCl 12.5 mg/5 ml oral elixer.Diphenhydramine HCl 12.5 mg/5 ml oral elixer is requested for use as a component of a compound drug for treatment of chemotherapy induced mouth sores associated with weight loss. The plan concluded that the requested drug is not eligible for coverage under Medicare Part D because they determined that the requested drug is an over the counter medication. However, in reviewing the National Drug Codes and FDA databases, the requested drug is a prescription medication; therefore it is eligible for coverage under Medicare Part D. The prescriber has indicated why all alternatives required by the Plan would likely not be as effective as the requested drug for the enrollee, and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is medically necessary. Our Physician Reviewer's opinion is that formulary exception criteria are metMintoxMedicare Part D does not cover non-prescription drugs. We checked FDA approved sources for the drug'sclassification or determined from other available resources that the drug is a non-prescription or OTC drug.Therefore, Mintox is not eligible for Part D coverage, and the Plan is not required to cover it under the PartD benefit.This decision does not address the medical necessity or appropriateness of the requested drug. It onlyestablishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for the Transdermal Verapamil Compound purchased March19, 2020. The Plan did not grant this request. We received this case to conduct an independent review.Medicare Part D does not cover drugs that are not FDA approved. A representative of the pharmacy statedthat bulk powder was used when compounding the prescription for the Transdermal Verapamil Compoundpurchased March 19, 2020. Bulk powders used in pharmacy compounding are not reviewed and approvedfor safety and efficacy by the FDA. Therefore, the Plan is not required to cover or provide reimbursementfor the Transdermal Verapamil Compound purchased March 19, 2020.This decision does not address the medical necessity or appropriateness of the requested drug. It onlyestablishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Thalomid. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Thalomid. The drug is requested to treat adenoid cystic carcinoma of the parotid gland, which is an off-label (non-FDA approved) use.The enrollee is a 70-year-old woman with adenoid cystic cancer of the parotid gland involving lungs and intracranial tissues. She has been treated with surgery, radiation, cryoablation and Thalomid. She has been on Thalomid since 2005. The prescriber requests Thalomid to treat her. The enrollee appealed the request stating the drug is to prevent the cancer from growing and without it the cancer will grow and kill her. She states the drug prevents more harmful and expensive chemo combinations.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. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. This reviewer did a PubMed search and found no supporting citations. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. For Part D drugs used in an anticancer chemotherapeutic regimen, a medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia or peer-reviewed medical literature in CMS-approved journals or publications.Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicare approved compendia and there was no peer-reviewed literature from an approved journal submitted to support the use of Thalomid for the diagnosed condition. As a result, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be covered under the Medicare Part D benefit for this condition. An exceptions request based on medical necessity cannot be considered because this drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage for Thalomid. This decision does not concern the medical necessity of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to provide a tiering exception for Procrit. The Plan did not grant this request. We received this case to conduct an independent review.Medicare law and Plan rules do not allow tiering exceptions for non-formulary drugs being covered through a formulary exception. The documentation in the record shows that Procrit is currently being covered for the enrollee through a formulary exception. Therefore, our decision is the Plan is not required to provide a tiering exception for Procrit.
Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Carbamazepine 200 mg, 270 per 90 days. The Plan did not grant this request.We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Carbamazepine 200 mg, 270 per 90 days. The drug is requested to treat convulsions. The Plan limits theamount of the drug to a 30 day supply. Per the Centers for Medicare and Medicaid Services informationrelated to COVID-19 dated 4/21/2020: Part D sponsors must suspend all quantity and days' supply limit sunder 90 days for all covered Part D drugs (as defined in 42 CFR 423.100) other than such limits resultingfrom safety edits. Therefore, an exception to the Plan's coverage criteria is medically necessary. OurPhysician Reviewer's opinion is that quantity limit exception criteria are met.Medicare rules allow a Part D Plan to manage its formulary by covering a limited quantity of certain drugs.A Plan must grant an exception if it determines that the requested dosage is medically reasonable andnecessary, consistent with the prescriber's statement. Based on a review of the available documentation,our Physician Reviewer's opinion is that an exception to the quantity limit criteria is met. Therefore, thePlan is required to cover the requested quantity of Carbamazepine 200 mg, 270 per 90 days.