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

At issue is Desvenlafaxine Succinate Extended Release tablet 24-Hour to treat anxiety disorder, unspecified, dysthymic disorder, and generalized 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 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 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 condition. 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 Anoro Ellipta 62.5/25-micrograms Inhaler to treat an unknown condition. The Part D plan denied the request. The requested drug is not on the plans formulary. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 you.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 Sildenafil Citrate 100 milligram tablet to treat unknown diagnosis. The Part D plan denied the request.We performed 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.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not Food and Drug Administration (FDA) approved, 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 Desoximetasone 0.25% ointment prescribed to treat the enrollee with left leg vasculitis limited to the skin and painful rash of the bilateral hands and feet. 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 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 shows the doctor prescribed Desoximetasone 0.25% ointment to treat left leg vasculitis limited to the skin and painful rash of the bilateral hands and feet. However, the Medicare approved compendia do not support the use of this drug for the enrollees conditions.A physician reviewed the appeal and determined that the plan is not required to cover Desoximetasone 0.25% ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Descovy 200-25 milligram tablet prescribed daily for unknown diagnosis. The Part D plan denied the request.  We received the case to perform an independent and de novo review. To make our decision, we 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 the requested drug from the mail-order pharmacy and was charged an amount that is less than or equal to the required coinsurance amount. We reviewed the plans formulary and Evidence of Coverage. In this case, the documentation shows the enrollee was in the coverage gap stage when the refill of the tier 3 drug was processed. The plan paid its share of the cost for the covered drug and the enrollee was responsible for their share of the remaining 25%. We determined that the plan calculated the enrollees cost share in the coverage gap stage correctly and no additional reimbursement is required.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsule prescribed daily for non 24-hour type circadian rhythm sleep wake 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 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.Hetlioz was prescribed to treat the enrollees non 24-hour type circadian rhythm 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 the 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: Unfavorable

At issue is Takhzyro 300-milligrams/2-milliliters Subcutaneous Injector to treat angioedema. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.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 condition. 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 Evenity 210 milligrams per 2.34 milliliters (2 syringes) prescribed to treat the enrollees condition. The Part D plan denied the appeal 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.Evenity is provided by the plan under a formulary exception. It is not on the plans 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 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 Trulance 3 milligram tablets prescribed to treat the enrollee with unspecified constipation.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 Trulance 3 milligram tablets to treat unspecified constipation. 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 Trulance 3 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregabalin 50 milligram tablets, initially prescribed to treat the enrollee with drug-induced constipation. 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.Upon reconsideration, documentation shows that the initial diagnosis of drug-induced constipation was submitted in error; and, the correct diagnosis code for the requested drug is M79.2 (neuralgia and neuritis, unspecified). 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 Pregabalin 50 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Livalo to treat an unknown condition. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The prescriber has not indicated that all alternatives required by the plan have been tried and failed, or why the plans required step therapy drugs would likely not be as effective as the requested drug.  Finally, the prescriber stated in their letter dated 9/2/2021 that the enrollee needs to continue Livalo because they are, 'allergic to statins.'  Of note Livalo is a statin.  Our physician reviewer's opinion is that neither step therapy nor step therapy exception criteria are met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Trelegy Ellipta 100-62.5-25-micrograms Powder for Inhalation to treat an unknown condition. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Trelegy Ellipta 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 condition. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the request and determined that the drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Breztri Aerosphere 160-9-4.8 microgram/actuation prescribed for chronic obstructive pulmonary 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 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 you. A physician reviewed your appeal and determined that the plan is not required to cover Breztri Aerosphere.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine Hydrochloride 100% powder to be used for the compounded drug Lidocaine 10% cream, prescribed to treat the enrollee with pugendal neuralgia, genital arousal disorder, and neuropathic vaginal pain. The Part D plan denied the appeal request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows Lidocaine 10% cream is a compounded drug and contains ingredients that are not covered by the Part D plan including the drug at issue, Lidocaine Hydrochloride 100% powder. In addition, drugs compounded from bulk powders are not United States Food and Drug Administration approved. We determined the plan is not required to cover the requested drug 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

At issue is a request for coverage of Modafinil 100 milligram tablets, 30 tablets per 30 days. 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 Modafinil 100 milligram per day has been prescribed for fatigue and hypersomnia associated with multiple sclerosis. 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. 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: Unfavorable

At issue is Tacrolimus 0.1% Ointment to treat erythema intertrigo. 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 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 condition. 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 Auryxia Tablet 1-Gram 210-milligram (Iron) Tablet 900-Tablets/50-days to treat other disorders of phosphorus metabolism. 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 asked your prescriber to send us a prescriber statement, a medically accepted indication (diagnosis), answers to prior authorization coverage criteria, answers to quantity limit exception coverage criteria, and medical records. However, we did not receive the documentation.The plan limits the amount of Auryxia to 360-tablets/30-days. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the condition or would be likely to cause harm. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that quantity limit criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Modafinil 200 milligram tablets. The Part D plan denied the request because the plans prior authorization requirements were not met, as there was not confirmation that the diagnosis of narcolepsy was confirmed with polysomnography and a multiple sleep latency test. 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 diagnosis originally provided to the plan by the prescriber is narcolepsy secondary to another medical condition. However, as noted by the plan, coverage for Modafinil for the treatment of excessive somnolence associated with narcolepsy requires that the narcolepsy be confirmed by polysomnography and a multiple sleep latency test. However, the submitted documentation does not include any test results to confirm the diagnosis of narcolepsy.At reconsideration, the prescriber has noted that Modafinil has been prescribed for the treatment of excessive daytime sleepiness concurrent with depression. Relevant medical records were requested but not provided. 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. 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: Unfavorable

At issue is Dexcom G6 Sensor prescribed to an enrollee with type 2 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 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 indicates Dexcom G6 Sensor is prescribed for an enrollee with type 2 diabetes. Medical supplies that are not directly related to the delivery of insulin to the body are not eligible for coverage under Part D drug benefits. However, this drug may be covered under Medicare Part B benefits. We determined that the plan is not required to cover Dexcom G6 Sensor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Albuterol Sulfate 2.5 milligram per 3 milliliters vial nebulizer prescribed to treat the enrollee with moderate persistent asthma. The Part D Plan denied the appeal request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows Albuterol Sulfate is being administered through a nebulizer and the enrollee does not currently residing in a long-term care facility. 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 the Albuterol Sulfate. Please consider submitting this 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 a request for coverage of Ipratropium-Albuterol 0.5-3 milligram per 3 milliliter nebulizer ampules prescribed for the treatment of chronic obstructive pulmonary 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 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 indicates that the Ipratropium Bromide-Albuterol Sulfate is going to be used with a nebulizer in the enrollees home. Medicare rules state that Medicare Part B pays for the rental and purchase of durable medical equipment. Payment will also be made under Medicare Part B for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals, which must be put directly into the equipment to achieve the therapeutic benefit of the durable medical equipment. Coverage under Part D is excluded for any drug for which payment would be available under Part B. We have determined that the Medicare Part D plan is not required to cover the requested drug. 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. Please submit the request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Hetlioz 20 milligram capsules prescribed for the management of circadian rhythm sleep disorder free running type, non-24-hour sleep-wake disorder. 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 provided medical records to sufficiently address 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 Febuxostat 40 milligram tablets prescribed for hyperuricemia and hyperuricosuria in nephrolithiasis. 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 shows the doctor prescribed Febuxostat to treat the enrollees condition of hyperuricemia and hyperuricosuria in nephrolithiasis. 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 Febuxostat.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyvanse 40-milligram capsule to treat attention deficit hyperactivity disorder, predominantly inattentive type. The Part D plan denied the request. The requested drug is not on the plans formulary. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 records provided do not support why other drugs on the plans formulary would not work for you.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 Diltiazem Hydrochloride 30 milligram tablet prescribed as a self administered drug in an outpatient setting. 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 plan submitted documentation that shows proof of payment for the drug has been provided by the enrollee. However, the plans claim information indicates the National Drug Code for the requested drug was either not valid or missing. We reviewed the submitted documentation and determined from the Food and Drug Administration records that the National Drug Code, 60687-595-11, is a valid code for Diltazem Hydrochloride. Therefore, the plan is required to reimburse the enrollee for the requested drug.