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

At issue is Lumakras 120-milligram tablets to treat KRAS G12C-mutated metastatic non-small cell lung cancer in an enrollee who has not received any prior systemic therapy. 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 diagnosis. There was no peer-reviewed, clinically relevant medical literature from a Medicare approved journal submitted to support this appeal. Therefore, 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 Tafinlar 75-milligram capsules to treat metastatic papillary thyroid cancer in combination with Mekinist. 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. Medicare-approved compendia do not contain any citations to support the use of the requested drug as prescribed, for treatment of the noted diagnosis. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, 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 a tiering exception request for Janumet XR 100-1,000-milligram tablet daily. The case was auto-forwarded by the plan.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.Janumet XR 100-1,000-milligram tablet 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 a tiering exception request for Ozempic 1-milligram/dose (2-milligrams/1.5-milliliter). The case was auto-forwarded by the plan.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.Ozempic 1-milligram/dose (2-milligrams/1.5-milliliter) 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 a direct member reimbursement for Shingrix vaccination. The Part D plan denied the request.We received a case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation does not include a valid receipt for payment for the vaccination at issue. Therefore, reimbursement cannot be allowed.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil 100-millgram tablets, 10 tablets per 10 days. 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 only Food and Drug Administration (FDA)-approved indication for the use of Sildenafil 100-millgram tablets is for the treatment of erectile dysfunction. Drugs when used for the treatment of sexual or erectile dysfunction are excluded from coverage under Medicare Part D. Therefore, the requested drug is not eligible for coverage under Medicare Part D. 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: Unfavorable

At issue is Hetlioz 20-milligram capsule daily to treat circadian rhythm sleep wake disorder. The case was auto-forwarded by the plan.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 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 Virt-Phosophorus 250 neutral tablets. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. Virt-Phosophorus 250 neutral tablets is available over the counter. Drugs that are available over the counter are excluded from coverage under Medicare Part D. In addition, drugs prescribed for use as vitamins and minerals 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 Nicotine 2-milligrams chewing gum for smoking cessation. 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.Nicotine 2-milligrams chewing gum is available over the counter. Drugs prescribed that are available over the counter 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 Levothyroxine Sodium powder compound. The Part D plan denied the appeal request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows Levothyroxine Sodium powder is a bulk powder used as an ingredient for a compounded drug. Bulk powders used for compounded drugs are excluded under Medicare Part D. Therefore, this drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ondansetron Orally Disintegrating Tablet 4-milligrams to treat nausea and vomiting, unspecified. 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 Tadalafil 20-millligram tablet. 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 documentation indicates that the requested drug has been prescribed for the treatment of World Health Organization (WHO) group 2-3 pulmonary hypertension. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug 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, 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 a tiering exception request for Carbidopa-Levodopa 50-100-milligram Extended Release tablet to treat an unstated diagnosis. 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 the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Carbidopa-Levodopa is a generic drug on Tier 2 of the plans formulary. There are no brand or generic drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the request and determined that the drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement of $13.12 for the purchase of Benzonatate 100-milligram capsules on May 11, 2021. 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 the case file carefully. We reviewed all documentation submitted.Benzonatate is a drug that is prescribed for cough relief. Drugs when used for the symptomatic relief of cough are excluded from coverage under Medicare Part D. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. 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: Unfavorable

At issue is Clobetasol 0.05-percent compounded spray. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We determined that the plan is not required to cover Clobetasol compounded spray. Drugs compounded from bulk powders are not Food and Drug Administration approved and are therefore not covered under Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Tizanidine Hydrochloride 2-milligram capsules. The Part D plan denied the request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation does not include proof of payment from the enrollee.We determined that the plan is not required to reimburse the enrollee for the drug at issue, as noted above.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Zolpidem Tartrate 10-milligram tablets. The Part D plan denied the request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation does not include proof of purchase from the enrollee.We determined that the plan is not required to reimburse the enrollee for the drug at issue, as noted above.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fenofibrate 120-milligram tablet to treat mixed hyperlipidemia. The case was auto-forwarded by the plan. 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 Modafinil 200-milligram tablets to treat unspecified hypersomnia, other fatigue, and other hypersomnia. 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.At reconsideration a diagnosis of excessive sleepiness due to narcolepsy was given. However, no documentation was provided by the prescriber to support this diagnosis. We requested information from the prescriber, but no information was received. 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 Vraylar 1.5-milligram capsules to treat other bipolar 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.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the enrollee has satisfied the plans prior authorization coverage criteria. We received additional documentation and included it in the review.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 Potassium Chloride 20 milliquivalent packet to treat congestive heart failure. 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 Lynparza 150-milligram tablets to treat metastatic triple negative breast cancer, PALB2 mutation. 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. Medicare-approved compendia do not contain any citations to support the use of the requested drug as prescribed, for treatment of the noted diagnosis. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, 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 a tiering exception request for Brilinta 90-milligram tablets to treat coronary artery 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.Brilinta is a brand drug on Tier 4 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 Lyrica 300-milligram capsules to treat fibromyalgia. 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, all alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the documentation does not support why all 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 Otezla 28 day starter pack to treat psoriasis vulgaris. The Part D plan denied the request. The requested drug is not on the plans formulary.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 medical records submitted support the enrollee has generalized plaque psoriasis. 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 all 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 Tymlos 3120-microgram/1.56-milliliter injection to treat age-related osteoporosis in a male enrollee. 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 a tiering exception request for Myrbetriq 50-milligram extended-release 24-hour tablets to treat increased frequency of urination. 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.Myrbetriq 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 LIdocaine 5% patch to treat dorsalgia. 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 medical records and a prescriber statement to support the enrollee has satisfied the plans prior authorization coverage criteria. However, we did not receive the requested information.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 Dextroamphetamine-Amphetamine 5-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.We requested additional information from the prescriber. Specifically, we requested medical records to support a diagnosis as the documents were conflicting. However, we did not receive the requested information. In order to establish medical necessity and confirm that the requested drug is being used for a medically accepted indication, as required by Medicare, medical records supporting that medically accepted indication are required. We did not receive information that could answer these medical necessity issues.  The requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.