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

At issue is Prednisone 10 milligram tablet prescribed daily for stem cell transplant. 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 also researched Medicare systems and reviewed the enrollment data available. We determined that the plan is not required to cover the drug. Medicare records indicate the enrollee received a stem cell transplant, which was covered by Medicare Part A. Therefore, the transplant is considered a Medicare covered transplant and the requested drug is eligible under Medicare Part B. Medicare rules state that a drug covered under Part B cannot be 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Motegrity 2-milligrams tablet to treat 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 reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level. Please note, this reconsideration decision was based on the plans 2021 coverage criteria.This drug is being provided by the plan under a formulary exception. It is not on the plans 2021 formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.A physician reviewer determined that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a 2022 plan year tiering exception request for Trulicity 0.75-milligram/0.5-milliliter pen injector to treat type II diabetes mellitus with hyperglycemia. 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.Trulicity is a biologic on Tier 3 of the plans 2022 formulary. There are no biologics of the same type on the lower tiers of the plans 2022 formulary to treat the same diagnosis. Therefore, this biologic is not eligible for a 2022 plan year 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 Myrbetriq 25-milligrams extended-release tablet to treat an overactive bladder with urinary urge incontinence. 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. Please note, this reconsideration decision was based on the plans 2022 coverage criteriaMyrbetriq 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 2022 formulary to treat the same diagnosis. Therefore, this drug/biologic 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 Aimovig 70-milligrams/milliliter Solution Auto-Injector to treat migraine unspecified, not intractable without status migrainosus. 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.We requested additional information from the prescriber. Specifically, we requested a prescriber statement, answers to prior authorization coverage criteria, and medical records. We received the prescriber statement, a generic statement that the enrollee does not tolerate oral medications well, answers to the prior authorization coverage criteria questions and included it in our review. However, we did not receive the requested medical records.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 Fentanyl 50-microgram/hour patch to treat chronic pain. 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 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 Infed 100 milligram/2 milliliter vial to treat stage 4 kidney 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.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 Simponi 100-milligram/milliliter subcutaneous injection solution to treat Crohn's 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.The use of the requested biologic 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 biologic, as prescribed, for the treatment of this diagnosis. Therefore, the requested biologic 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 Jublia 10-milligram topical solution to treat onychomycosis. 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, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the documentation does not support why the formulary alternatives, required by the plan 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 Budesonide 0.5-milligram/2-milliliter nebulizer solution. 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. Based on the information provided, we determined the drug may be eligible for coverage under Part B under Medicare rules.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 Otezla 30-milligram tablets to treat Darier's 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.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 2022 plan year tiering exception request for Fenofibrate 160-miliigram tablets to treat high cholesterol and hyperlipidemia. 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.Fenofibrate is a generic drug on Tier 3 of the plans 2022 formulary. The prescriber has not addressed all drugs on the lower tiers of the formulary to treat the enrollees conditions. The prescriber has not provided patient specific clinical rationale as to why each lower-tiered drug has been tried and failed, or is contraindicated. Therefore, the tiering exception criteria have not been met. As such, the requested drug is not eligible for a 2022 plan year tiering exception.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier. The drug will continue to be covered at the Tier 3 copay.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Pomalyst 4-milligram capsules to treat refractory multiple myeloma. 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 documentation indicates the prescriber ordered the drug at issue for the enrollees diagnosis. The submitted documentation indicates the enrollee has failed previous therapy and is to use the drug at issue in combination with Velcade and Dexamethasone. The Medicare approved compendium, Clinical Pharmacology, contains a citation to support the use of the drug for the noted diagnosis.The plan has prior authorization coverage criteria that must be met prior to approval. The enrollee satisfies the Plans coverage criteria. The plan's prior authorization coverage criteria requires a medically accepted indication. As the Medicare approved compendia contain a citation in support of the drug at issue for the enrollee's noted diagnosis, the plan's prior authorization coverage criteria has been met. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is coverage for Ramelteon 8-milligram tablets to treat primary insomnia. The Part D plan auto-forwarded the request for coverage to us for review. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted.The Part D plan is responsible for determining that a drug is being prescribed for a medically accepted indication. As outlined in the Medicare approved compendia, the use of Ramelteon for the treatment of insomnia is a medically-accepted indication for the drug. The plan has no additional utilization management requirements for this drug. As such, coverage for the drug can be allowed.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 Nurtec 75-milligram orally disintegrating tablets for prophylaxis against chronic 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 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 Simponi 100-milligram/milliliter subcutaneous injection solution to treat hidradenitis suppurativa. 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 biologic 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 biologic, as prescribed, for the treatment of this diagnosis. Therefore, the requested biologic is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested biologic is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Prednisone 5-milligram tablets prescribed for immunosuppressive therapy following a pancreas transplant. 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 also researched Medicare systems and reviewed the enrollment data available. Medicare records show that the enrollee underwent a pancreas transplant procedure on August 20, 2000. Medicare records also show that the enrollee had Medicare Part A coverage from the date spans of June 1, 1998, through June 30, 2001, and June 1, 2013, through the present.  Therefore, Medicare records confirm that the enrollee had Medicare Part A coverage when the pancreas transplant took place on August 20, 2000. As such, the transplant is considered a Medicare-covered transplant and the requested drug is eligible under Medicare Part B. Medicare rules state that a drug covered under Part B cannot be 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Tacrolimus 1-milligram capsules prescribed for immunosuppressive therapy following a pancreas transplant. 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 also researched Medicare systems and reviewed the enrollment data available. Medicare records show that the enrollee underwent a pancreas transplant procedure on August 20, 2000. Medicare records also show that the enrollee had Medicare Part A coverage from the date spans of June 1, 1998, through June 30, 2001, and June 1, 2013, through the present.  Therefore, Medicare records confirm that the enrollee had Medicare Part A coverage when the pancreas transplant took place on August 20, 2000. As such, the transplant is considered a Medicare-covered transplant and the requested drug is eligible under Medicare Part B. Medicare rules state that a drug covered under Part B cannot be 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Vraylar 3-milligram capsule. 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.This drug is being provided by the plan at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules. A physician reviewer determined that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Cyclobenzaprine Hydrochloride 5-milligram tablets. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted including the case file from the plan and any information submitted at the reconsideration level.During this review, a request was submitted to the prescriber to clarify the diagnosis and to address the plans prior authorization requirements for coverage of this drug. We received additional documentation from the prescriber and included it in the review.The submitted documentation indicates that the Cyclobenzaprine Hydrochloride has been prescribed for the treatment of muscles spasms of the back as a result of a chronic condition, lumbar radiculopathy/sciatica. However, the use of the requested drug to treat the noted condition is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the drug is not being prescribed for a non-medically accepted indication.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armodafinil 150-milligram tablets to treat excessive daytime fatigue due to Parkinson's 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.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 Xifaxan 550-milligram tablets to treat irritable bowel syndrome with diarrhea. 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 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 Neurontin 400-milligram capsules to treat neuropathic pain. 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 all formulary alternatives were tried and failed or were contraindicated. 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 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 Ozempic 1-milligram per dose (4-milligrams per 3-milliliters) pen-injector to treat diabetes. 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.Ozempic 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 Lexapro 20-milligram tablet to treat anxiety 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 all formulary alternatives were tried and failed or were contraindicated. We received additional documentation and included it in the review.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 the formulary alternatives, required by the plan would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm. Please note, this reconsideration decision was based on the plans 2022 coverage criteria.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.