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

At issue is Tacrolimus 1-milligram tablet to treat chronic idiopathic urticaria and mast cell activation. 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 use of the requested drug to treat the provided diagnoses are off-label uses. 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 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 a prior authorization request for Aranesp 100 microgram/0.5 milliliter injection prescribed for anemia in chronic kidney disease without dialysis. 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. We requested additional documentation from the prescribing physician. Specifically, we requested medical records and a prescriber statement to support the enrollee met the plans prior authorization coverage criteria. We received additional documentation and included it in this review.The submitted documentation includes a physician supporting statement and laboratory results. The documentation supports that the enrollee satisfies the plan's prior authorization coverage criteria. The enrollee has a diagnosis of anemia in chronic kidney disease in an enrollee not on dialysis, and the biologic is to be used to maintain a level of 10 grams/deciliter. The enrollees hemoglobin levels prior to therapy were less than 10 grams/deciliter and the enrollees ferritin levels were greater than 80 nanograms/milliliter.A physician reviewed the appeal and determined that the requested biologic is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is prescribed Androderm 4 milligram/24 hour patch prescribed for male hypogonadism. 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 Androderm was prescribed to treat male hypogonadism. 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 Androderm. 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 Trospium Chloride 20 milligram tablet prescribed for overactive bladder. The Part D plan denied your 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. 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. Although the prescriber indicates Myrbetriq cannot be crushed to give via G-tube, the drug requested, Trospium also is not to be crushed. Therefore, there is no substantive reason why the formulary drug Myrbetriq is not able to be prescribed. In this case, the medical records do not support why all the 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 Trospium Chloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tadalafil 5 milligram tablets prescribed for urinary symptoms associated with benign prostatic hyperplasia. 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.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 the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Tadalafil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Spravato 56 milligram spray prescribed for major depressive disorder. The Part D plan denied the request.  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 Spravato is being prescribed to the enrollee for treatment of major depressive disorder. Medicare law specifically excludes coverage for any drug for which payment would be available under Medicare Parts A or B for that individual. Medicare Part B pays for services and supplies incident to the service of a physician (or other practitioner).  Spravato is a type of drug that must be administered under direct observation of a health care provider and monitored for at least two hours after administration. The Food and Drug Administration has mandated a Risk Evaluation and Mitigation Strategy for Spravato. This strategy requires that Spravato be only dispensed and administered to patients in a medically supervised healthcare setting that monitors the enrollee. We determined that the drug is eligible under Medicare Part B. Therefore, the Part D plan is not required to cover Spravato.  This 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 Spravato 50 milligram spray prescribed for major depressive disorder, single episode, severe without psychotic features. The Part D plan denied the request.  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 Spravato is being prescribed to the enrollee for treatment of major depressive disorder, single episode, severe without psychotic features. Medicare law specifically excludes coverage for any drug for which payment would be available under Medicare Parts A or B for that individual. Medicare Part B pays for services and supplies incident to the service of a physician (or other practitioner).  Spravato is a type of drug that must be administered under direct observation of a health care provider and monitored for at least two hours after administration. The Food and Drug Administration has mandated a Risk Evaluation and Mitigation Strategy for Spravato. This strategy requires that Spravato be only dispensed and administered to patients in a medically supervised healthcare setting that monitors the enrollee. We determined that the drug is eligible under Medicare Part B. Therefore, the Part D plan is not required to cover Spravato.  This 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 Xiidra 5% Droperette to treat dry syndrome bilateral lacrimal glands. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 has not provided patient specific clinical rationale, supported by medical records, as to why all formulary alternatives required by the plan would likely not be as effective as the requested drug for this condition, and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not medically necessary. 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 Cyanocobalamin solution 1000 micrograms per milliliter solution prescribed to treat pernicious anemia. The Part D plan denied the appeal request.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.According to Medicare rules, drugs that fall into the category of vitamins and minerals are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover the Cyanocobalamin. This decision does not address 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

You requested Freestyle Libre 14 day sensor prescribed as directed. 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 information submitted at the reconsideration level. The record shows you requested coverage for Freestyle Libre 14 day sensor. However, this product may be eligible for coverage under Medicare Part B. Medicare rules state drugs and medical supplies not directly associated with the injection of insulin are not covered under Part D. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.We determined that the plan is not required to cover Freestyle Libre 14 day sensor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Modafinil 100 milligram tablets prescribed for excessive daytime sleepiness associated with Parkinsonism. 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 Modafinil for excessive daytime sleepiness associated with Parkinsonism. 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 Exemestane 25 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.We requested additional information from the prescribing physician. Specifically, we requested medical records to support a covered diagnosis and a prescriber statement to address whether the enrollee had tried and failed the lower-tier alternative medication. We received the requested information and included it in the review.The medical records indicate the prescriber ordered the Exemestane at issue for the enrollees stage 1 breast cancer. The Medicare approved compendia support the use of the drug for the enrollees condition.Exemestane is a generic drug on Tier 4 of the plans formulary. The prescriber submitted a supporting statement. The supporting statement did not address why all the drugs available on the lower tiers of the plans formulary would not work. 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 Levalbuterol Hydrochloride 1.25 grams per 3 milliliters nebulizer solution prescribed to treat chronic obstructive pulmonary disease. The Part D plan denied the appeal request.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. The record shows Levalbuterol Hydrochloride is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover Levalbuterol Hydrochloride. Please submit the appeal request to Medicare Part B. 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 tiering exception request for Dexmethylphenidate Hydrochloride 10-milligram tablet to treat attention deficient hyperactivity disorder. 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.Dexmethylphenidate Hydrochloride is a generic drug on Tier 3 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.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ubrelvy 100 milligram tablets prescribed to treat migraines. The Part D plan denied the appeal request for a formulary exception.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.The documentation shows the doctor prescribed Ubrelvy 100 milligram tablets to treat migraines. The office progress note of October 12, 2020, shows the enrollee presented with complaint of chronic migraines. Upon redetermination, the Part D plan denied the appeal stating that the formulary exception requirements were not satisfied. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed the appeal and determined that the plan is not required to cover Ubrelvy 100 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Voriconazole 200 milligram tablet prescribed for acute myeloblastic leukemia not having achieved remission and fungal infection prophylaxis. 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 information submitted at the reconsideration level. The documentation show Voriconazole was prescribed to treat acute myeloblastic leukemia not having achieved remission and fungal infection prophylaxis. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Voriconazole.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tolterodine Tartrate 4 milligram extended release capsules prescribed for overactive bladder. The Part D plan denied the request as the drug has step therapy requirements that must be met. 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 documentation shows the prescriber ordered Tolterodine Tartrate to treat the enrollees overactive bladder. The plan has step therapy 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 the appeal and determined that the plan is not required to cover Tolterodine Tartrate. The documentation does not support the enrollee has tried any of the required medications identified by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil Citrate 20 milligram tablets prescribed for the enrollees condition. The Part D plan denied the request for a tiering exception and a quantity limit 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.Sildenafil Citrate is a generic drug on Tier 2 of the plans formulary. There are no drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.The prescriber ordered a quantity of medication, 270 tablets per 30 days, in excess of the plans allowance. The Medicare approved compendia do not support the dosage requested by the prescriber for the enrollees condition. The plan allows for a quantity of 90 tablets per 30 days. A quantity limit exception cannot be granted.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception or quantity limit exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Zolpidem Tartrate 12.5 milligram tablets prescribed for insomnia. 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

The enrollee requested Myfortic 360 milligram tablet DR prescribed to prevent transplant rejection. 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 information submitted at the reconsideration level.The record shows the enrollee had a heart transplant on August 6, 2020. According to Medicare enrollment records, the enrollee was entitled to Medicare Part A coverage at the time of the transplant. Therefore, the transplant is considered a Medicare covered transplant and Myfortic is eligible for coverage under Medicare Part B. Medicare Part B covers prescription drugs used in immunosuppressive therapy furnished to an enrollee who has received an organ transplant. Drugs which are eligible for Part B coverage are excluded from Part D coverage by Medicare law. We determined that the Medicare Part D plan is not required to cover Myfortic. 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. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tacrolimus 1 milligram tablets prescribed daily following a kidney transplant. 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 also researched Medicare systems and reviewed the enrollment data available. Based on the information provided, the drug is eligible for Part B coverage. 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 drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Saxenda 3 milligram per 0.5 milliliter (18 milligrams per 3 milliliters) pen injector prescribed to treat morbid obesity. The Part D plan denied the appeal request.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.The record shows the doctor prescribed Saxenda 3 milligram per 0.5 milliliter (18 milligrams per 3 milliliters) pen injector to treat obesity. We determined the plan is not required to cover Saxenda because it is excluded from coverage under Part D. 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

The enrollee requested Acetaminphen 325 milligram caplet for unknown diagnosis.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 the enrollee received Acetaminophen as a self-administered drug in the hospital. According to Medicare rules, drugs that are considered over-the-counter are excluded from coverage under Part D. Acetaminophen is on Medicares excluded list of drugs because it does not meet the definition of a Part D drug. In addition, the plans Evidence of Coverage indicates that the supplemental benefit permits coverage for certain approved over-the-counter drugs/products, but only when ordered online by mail order. Therefore, we determined that the Part D plan is not required to cover Acetaminophen or provide reimbursement to the enrollee.