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

At issue is Oxycodone Hydrochloride 15 milligram extended release tablets prescribed for chronic pain. The case was auto-forwarded by the plan.  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 plan has limited access to opioid medications for the enrollee. The plan will not cover any opioid drugs for the enrollee. This drug may be considered medically necessary if all doctors who prescribe the enrollees opioid pain medications come to an agreement that the drug at issue is an appropriate therapy for the enrollee. The prescribing physician has not contributed to this process or submitted supporting documentation.A physician reviewed the appeal and determined the enrollee is considered at-risk. The physician reviewer also determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tretinoin 0.05% cream prescribed for molluscum contagiosum and dermatitis. 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 the drug at issue for the enrollees noted condition. 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 a formulary exception request for Botox 100 units solution for injection prescribed to treat the enrollee with bilateral hand dystonia in the setting of idiopathic Parkinsons disease. 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 documentation shows the doctor prescribed Botox 100 units solution for injection to treat bilateral hand dystonia in the setting of idiopathic Parkinsons disease. 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 Botox 100 units solution for injection.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xarelto 20 milligram tablets prescribed for atrial fibrillation. 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.Xarelto is a brand drug on Tier 3 of the plans formulary. There are no other 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 a formulary exception request for Tremfya 100 milligram/milliliter injector prescribed for psoriasis vulgaris. 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 did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed the appeal and determined that the plan is not required to cover Tremfya.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Prolia 60 milligram/milliliter syringe prescribed for post-menopausal osteoporosis. 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. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The prescriber has addressed the Plans coverage criteria and has indicated that the patient has tried and failed the required alternative, in this case, the patient has tried Alendronate and developed hypercalcemia. The enrollee has satisfied the plan's coverage criteria for Prolia.A physician reviewed your appeal and determined that the plan is required to cover Prolia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolic Acid 360 milligram tablet prescribed for dermatomyositis. 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. The prescriber indicates Mycophenolic Acid 360 milligram tablet is prescribed to treat dermatomyositis. However, Medicare approved compendia do not support the use of this drug for this condition.  A physician reviewed your appeal and determined that the plan is not required to cover Mycophenolic Acid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Wakix 17.8 milligram tablet prescribed for idiopathic hypersomnia. 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. The prescriber indicates Wakix 17.8 milligram tablet is prescribed to treat idiopathic hypersomnia. However, Medicare approved compendia do not support the use of this drug for this condition.  A physician reviewed your appeal and determined that the plan is not required to cover Wakix.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Combigan 0.2%-0.5% ophthalmic solution. The Part D plan denied the request because the drug was not 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 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. Although the plan denied the requested drug stating that it was not on the plans formulary, Combigan 0.2%-0.5% ophthalmic solution is included on Tier 4 of the formulary submitted by the plan. The plans formulary does not include any prior authorization, step therapy, or quantity limit requirements for the drug. The documentation indicates that the Combigan in being used for the treatment of bilateral primary open-angle glaucoma, which is a medically accepted indication for the drug, as outlined in the Medicare approved compendia. Therefore, the drug is being used for a medically accepted indication and is included on the submitted formulary. 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 compounded drug Amphoterocin B oral solution prescribed for oral thrush. The 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.We determined that the plan is not required to cover the compounded drug Amphoterocin B oral solution. According to Medicare rules, drugs that fall into the category of bulk powders are excluded from coverage under Part D. Therefore, Amphoterocin B powder does not meet the definition of a Part D drug. We reviewed Food and Drug Administration (FDA)-approved sources for the drugs classification or determined from other available resources that the Glycerin 100% liquid and Syrspend SF oral suspension are over-the-counter drugs and therefore, not eligible for Part D coverage. 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

At issue is a formulary exception request for Tirosint 25 microgram capsules prescribed for other specified hypothyroidism. 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 did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed the appeal and determined that the plan is not required to cover Tirosint.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synthroid 88 microgram tablet prescribed for hypothyroidism. 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. 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 prescriber does not indicate why all of the other alternatives on the plans formulary would not work.A physician reviewed your appeal and determined that the plan is not required to cover Synthroid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Megestrol Acetate 40 milligram tablets prescribed for weight loss due to metabolic encephalopathy. 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 Megestrol Acetate because it was prescribed for weight loss. Drugs to treat anorexia, weight loss, or weight gain are excluded from 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 Lynparza 150 milligram tablets prescribed for stage IV lung cancer. 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 the drug at issue for the enrollees noted condition. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. There were no Medicare approved journal articles submitted to support the use of the drug for the enrollees noted 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 Contrave 8-90 milligram extended release tablets prescribed for morbid obesity. 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 Contrave because it was prescribed for weight loss. Drugs to treat anorexia, weight loss, or weight gain are excluded from 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 Lidocaine 5% ointment prescribed for post-herpetic neuralgia. The Part D plan denied the request. Of note, the appellant further requested a quantity of drug greater than the plans allowance.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 the drug at issue for the enrollees noted condition. 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, and a quantity limit exception cannot be granted.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 request for coverage of Pregabalin 50 milligram capsules. The Part D plan denied the request for coverage because there was insufficient documentation to determine if the plans prior authorization requirements met.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 submitted to the plan indicates that Pregabalin was prescribed for the treatment of Parkinsons disease. 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.At reconsideration, the prescriber has noted that Pregabalin has been prescribed for the treatment of diabetic peripheral neuropathy. However, no medical records have been submitted to validate this change in diagnosis, or additional diagnosis. Therefore, 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. Since the drug is not eligible for coverage, the plans prior authorization requirements are 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 Arikayce 590 milligram/8.4 milliliter nebulizer solution prescribed for mycobacterium avium complex 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 the drug at issue for the enrollees noted condition. The documentation does not support a negative sputum culture following six months of a multidrug background regimen therapy. 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 Phenazopyridine Hydrochloride 100 milligram tablets prescribed for tubulointerstitial nephritis. 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 drug at issue is not Food and Drug Administration approved. 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 a prior authorization request for Prolia 60 milligram/milliliter injection solution prescribed for osteoporosis. 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 information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the enrollee satisfies the plan's prior authorization coverage criteria. However, we did not receive the requested information.The submitted documentation 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: Favorable

At issue is Repatha Sureclick 140 milligram/milliliter auto-injector prescribed for hyperlipidemia and established cardiovascular disease. 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 records submitted at the reconsideration level. The prescriber indicates they prescribed Repatha SureClick 140 milligram/milliliter auto-injector to treat hyperlipidemia with established cardiovascular disease. The documentation submitted supports the enrollee has been on Atorvastatin 80 milligrams for over 90 days with continued cholesterol level over 90 on the maximum dose and the prescribing physician is a cardiologist. The documentation provided supports the plan's prior authorization requirements have been met. A physician reviewed your appeal and determined that the plan is required to cover Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Xeomin (IncobotulinumtoxinA) 100 unit powder for reconstitution for intramuscular injection. 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 documentation indicates that Xeomin has been prescribed for the treatment of arthralgia associated with temporomandibular joint dysfunction and migraines. However, the Medicare approved compendia do not contain any citations to support the requested drug, as prescribed, to treat the noted conditions. Therefore, the drug is being prescribed for non-medically accepted indications 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: Unfavorable

At issue is a formulary exception request for Nucynta 50 milligram tablets prescribed for chronic pain and fibromyalgia. 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 did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed the appeal and determined that the plan is not required to cover Nucynta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Ajovy 225 milligram per 1.5 milliliter subcutaneous auto injection pen prescribed for migraine prophylaxis. 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. Ajovy is not included in the plans formulary (list of covered drugs). The prescriber has not provided sufficient patient specific clinical rationale, supported by medical records, as to why the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a formulary exception request for Repatha Sureclick 140 milligram/milliliter auto injector prescribed for pure hypercholesterolemia. 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 the requested biologic for the enrollees noted condition. Furthermore, the prescriber has submitted a statement and medical records to support the enrollee has an intolerance to the formulary alternatives.A physician reviewed the appeal and determined that the plan is required to cover Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pimecrolimus 0.1% cream prescribed for red scrotum syndrome. 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 the drug at issue for the enrollees noted condition. 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.