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

At issue is a prior authorization request for Cosentyx 150 milligram/milliliter pen injector prescribed for plaque psoriasis and psoriatic arthritis. The Part D plan denied coverage.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 records submitted at the reconsideration level. The documentation on hand includes a physician supporting statement. The supporting statement does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.A physician reviewed the appeal and determined that the requested biologic is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Azasite 1% solution prescribed for rosacea. We received the 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 record shows the enrollee requested the plan to provide reimbursement for Azasite 1% solution. However, the plan did not approve coverage because Azasite 1% solution is a non-formulary drug and not covered by the enrollee's plan. Therefore, we determined that the plan is not required to reimburse the enrollee. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aspirin 81 milligram low-dose chewable tablets.The QIC 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.Aspirin 81 milligram low-dose chewable tablets is available over the counter. According to Medicare Drugs prescribed that are available over the counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage. Therefore, we determined that the plan is not required to reimburse the enrollee for Aspirin 81 milligram low-dose chewable tablets. 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 Auryxia 210 milligram tablet prescribed three times per day for hyperphosphatemia associated with chronic kidney disease in an enrollee not on dialysis. 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. This includes the case file from the plan and any information submitted at the reconsideration level.The doctor prescribed Auryxia to treat the enrollees hyperphosphatemia associated with chronic kidney disease. The enrollee is not on dialysis.  The Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Auryxia.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Taladafil 20 milligram tablets prescribed for erectile dysfunction. The Part D plan denied the enrollee's request. We received the 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 record shows that Tadalafil was prescribed to the enrollee for use to treat sexual or erectile dysfunction. We determined that the plan is not required to cover the Tadalafil. Medicare excludes certain drugs from Part D coverage. Tadalafil is an excluded drug when used to treat sexual or erectile dysfunction; or to treat a condition other than sexual or erectile dysfunction for which the drug has not been approved by the Food and Drug Administration. The record does not indicate that the plan provides supplemental coverage for Tadalafil. Therefore, the plan is not required to cover it. 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 a prior authorization request for Hetlioz 20 milligram capsules prescribed for non-24 hour sleep/wake disorder. The Part D plan denied coverage.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. The QIC has made 2 or more attempts to request a case file or the returned case file request form indicating no coverage determination/no redetermination. The documentation on hand does not indicate that the enrollee satisfies the plan's prior authorization 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

The enrollee requested Breo Ellipta 100-25 microgram with device prescribed for unknown diagnosis. The Part D plan denied the enrollees request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows Breo Ellipta (Fluticasone Furoate-Vilanterol) was given as a self administered drug to the enrollee while inpatient in the hospital. The National Drug Code, 0173-0859-14, provided for the Breo Ellipta is not listed with the Food and Drug Administration as a valid code for this drug. Therefore, we determined the plan is not required to cover or provide reimbursement for the Breo Ellipta. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Calquence 100 milligram capsule prescribed two tablets daily for B-cell prolymphocytic leukemia. 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. This includes the case file from the plan, and any records submitted at the reconsideration level.The medical records show the doctor prescribed Calquence to treat the enrollees B-cell prolymphocytic leukemia. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The records show the enrollee has B-cell prolymphocytic leukemia which is a rare variant of chronic lymphocytic leukemia that can evolve from chronic lymphocytic leukemia. It is a much more aggressive disease entity than chronic lymphocytic leukemia with increase of prolymphocytes. It is often times treated as chronic lymphocytic leukemia is treated, specifically the B-cell type. Per the Food and Drug Administration, calquence is indicated in chronic lymphocytic leukemia. Per the National Comprehensive Cancer Network, Calquence is indicated as a single agent first line for chronic lymphocytic leukemia. The documentation provided shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Calquence.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tymlos 3120 microgram/1.56 milliliter injection prescribed for age-related osteoporosis in a male. 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.The submitted documentation indicates the prescriber ordered Tymlos for age-related osteoporosis in a male. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.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 Entresto 97-103 milligram tablets prescribed for the enrollees condition. The Part D plan denied the request for a tiering exception.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.Entresto is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Accu-Chek test strip prescribed for unknown diagnosis. The Part D plan denied the enrollees request.We requested the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The record shows the Accu-Chek test strip was purchased without a prescription. Therefore, the plan is not required to cover or provide reimbursement for the drug.To pursue payment, please update your insurance information at the pharmacy where you purchased these drugs and ask to reprocess the claim.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Testosterone 1.62% (1.25 gram) gel packets. 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. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation indicates that Testosterone has been prescribed for the treatment of late-onset (age-related) male hypogonadism. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. As noted in the Medicare approved compendium, American Hospital Formulary Service Drug Information (AHFS-DI), the safety and efficacy of testosterone replacement therapy in men with low testosterone concentrations related to aging have not been established. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Fentanyl 12 microgram/hour transdermal patch, 10 patches per 30 days, prescribed for pain due to lumbar radiculopathy    The Part D plan denied the request.  We received a reconsideration 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.  The prescriber submitted a completed, signed and dated prior authorization request form and supporting medical records.  The records support that the prior authorization requirements were satisfied.  The documentation satisfies the plans coverage criteria.  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 Procrit 10,000 units per milliliter prescribed weekly for anemia associated with chronic kidney disease in patient not on dialysis. 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. This includes the case file from the plan and any records submitted at the reconsideration level.The medical records show the doctor prescribed Procrit to treat the enrollees anemia associated with chronic kidney disease in patient not on dialysis. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The records show the enrollees hemoglobin on July 16, 2021, was 7.3 grams per deciliter and Procrit is required to avoid blood transfusions. The documentation provided shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Procrit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Evenity 210 milligrams, two 105 milligram per 1.17 milliliter prefilled subcutaneous injection syringes, prescribed for postmenopausal osteoporosis. 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 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. Evenity is not included in the plans formulary (list of covered drugs). The prescriber has noted at reconsideration that the enrollee was offered the formulary alternative medication, Forteo. However, the enrollee refused to start Forteo due to an extreme discomfort with the idea of having to self-administer an injectable medication. However, the requested drug is also an injectable medication. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Itraconazole 100 milligram capsules prescribed for common variable immunodeficiency and acremonium infection. 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.The submitted documentation indicates the prescriber ordered Itraconazole for common variable immunodeficiency and acremonium infection. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.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 coverage for Nuplazid 34 milligram capsules prescribed for hallucinations and delusions associated with Parkinsons disease psychosis. 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 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. The plan has prior authorization requirements that must be met before coverage of this medication will be approved. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. 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 Forteo 620 micrograms per 2.48 milliliter subcutaneous injection syringe. 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 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 prescriber initially indicated that the enrollee did not have postmenopausal osteoporosis. At reconsideration, the prescriber has marked yes on a form that the enrollee does have postmenopausal osteoporosis. However, the submitted medical records do not validate that the 46 year-old enrollee is postmenopausal. The diagnosis listed in the progress notes is other osteoporosis without current pathological fracture. The Medicare approved compendia do not contain any citations to support the use of Forteo for the treatment of other osteoporosis without current pathological fracture. There is insufficient documentation to determine if the requested drug is being prescribed for a medically accepted indication. As such, the requested drug is not eligible for coverage under Medicare Part D. 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 Ofev 150 milligram capsule prescribed for idiopathic pulmonary fibrosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation shows Ofev was prescribed to treat idiopathic pulmonary fibrosis. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Ofev. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Hetlioz 20 milligram capsules prescribed for non-24 hour sleep/wake disorder. The Part D plan denied coverage.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 records submitted at the reconsideration level. The documentation on hand includes a physician supporting statement. The supporting statement does not indicate that the enrollee satisfies the plan's prior authorization 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 Cambia 50 milligram powder packet prescribed for migraines. 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. This includes the case file from the plan and any information submitted at the reconsideration level. The prescriber indicates the enrollee has tried multiple medications with no relief. However, Cambia powder packet 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 medical records do not support why all other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Cambia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Linzess 290 microgram capsules prescribed for the enrollees condition. The Part D plan denied the request for a tiering exception.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.Linzess is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsule prescribed for non-24 hour sleep-wake disorder. We received a reconsideration request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. We did not receive the documentation requested.The medical records show Hetlioz 20 milligram capsule was prescribed for non-24 hour sleep-wake disorder. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Hetlioz. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Nystop 100,000 units per gram topical powder prescribed weekly for intertriginous dermatitis. 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. This includes the case file from the plan and any records submitted at the reconsideration level.The medical records show the doctor prescribed Nystop to treat the enrollees intertriginous dermatitis. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The records show the enrollee was using the drug topically for treatment of active cutaneous or mucocuaneous candidiasis. The documentation provided shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Motegrity 2 milligram tablets prescribed for chronic idiopathic constipation. 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. This includes the case file from the plan and any information submitted at the reconsideration level.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the enrollee. We received the documentation and included it in our review.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 medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Motegrity.