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

At issue is coverage for Febuxostat 80 milligram tablet to treat gout. 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 available documentation. The requested drug is not on the plans formulary. To grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed or must be deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale as to why the alternative drugs on the plans formulary to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Additionally, the submitted documentation does not support that the enrollee has tried and failed all of the formulary alternative drugs. Therefore, the formulary exception requirements have not been met. 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 coverage for Promacta 12.5 milligram tablet to treat idiopathic thrombocytopenic purpura. The Part D plan denied the request for coverage because the following prior authorization requirement was not met: the enrollee must still be at risk for bleeding complications.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation supports that all of the plans requirements for coverage have been satisfied. Specifically, at reconsideration, the prescriber has clarified that the enrollee will still be at risk for bleeding complications without the requested drug. In addition, the submitted medical records support that the plans remaining prior authorization requirements for continued coverage of this drug have been met, as well. The records show that the enrollee has a diagnosis of idiopathic thrombocytopenic purpura; the enrollee has a current platelet count of less than 400,000 per microliter; the enrollee is responding to therapy as evidenced by an increased platelet count; and the enrollee does not have a previous documented failure with the requested drug. Therefore, the plans prior authorization requirements have been met and coverage for the drug is supported.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 coverage for Zolpidem Tartrate 10 milligram tablet to treat insomnia. 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 available documentation.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted medical records do not confirm that all of the plans requirements for coverage have been satisfied. Furthermore, the available documentation does not support the medical necessity for an exception to the plans prior authorization requirements.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 coverage for Testosterone Cypionate 100 milligrams per milliliter, 1.5 milliliters every 10 days, to treat male hypogonadism. 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 available documentation.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation supports that all of the plans requirements for coverage have been satisfied. Specifically, this request is for continuation of therapy. Note that the plan denied stating that they did not have confirmation from the prescriber that the enrollee's symptoms had improved compared to baseline and that the enrollee was tolerating the treatment. In the reconsideration appeal dated 7/28/2023, the prescriber sent office notes and a prescriber statement. The prescriber stated that the enrollee's symptoms have improved and that they were tolerating the treatment. Therefore, the plans prior authorization requirements have been met and coverage for the drug is supported.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 coverage for Promethazine Hydrochloride 12.5 milligram tablet to treat chemotherapy-induced nausea and vomiting. 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 available documentation.In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. 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 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

A reconsideration request was auto-forwarded from the plan to review the at-risk determination. The plan has imposed a restriction on opioids for the enrollee. The enrollee cannot exceed 90 morphine miligram equivalent dosage per day.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 records show the plan imposed a restriction on the enrollee. The enrollee's cannot exceed 90 morphine milligram equivalent dosage per day. There was no supporting documentation from the prescriber to show it was medically necessary to exceed the plan's restriction. A physician reviewed the appeal and determined the plans restriction is appropriate as there is a risk of obtaining an unsafe quantity of frequently abused drugs (i.e., opioids and benzodiazepines) when receiving prescriptions from multiple prescribers.In conclusion, the decision of the QIC is unfavorable.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary and tiering exception request for Prostaglandin/Alcohol/Phentolamine Mesylate/Papaverine Hydrochloride/Mannito/Sodium Bisulfite/Edstate Disodium/Benzyl Alcohol/Water bulk powder compounded drug prescribed to treat (diagnosis). The Part D plan denied/auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.Drugs that fall into the category of bulk powders do not meet the definition of a Part D drug. The requested drug is considered a bulk powder/ or is consistent of bulk powder ingredients and is excluded from coverage under Part D. 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 coverage for Xifaxan 550 milligram tablets to treat flatulence and loose stools. 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 available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. 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 being prescribed for a non-medically accepted indication. A tiering exception cannot be allowed for a drug that has not been approved for coverage.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 coverage for Repatha Pushtronex 420 milligram per 3.5 milliliter injection solution to treat familial hypercholesterolemia. The Part D plan auto-forwarded the case to us for review.We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. The submitted documentation does not validate that all of the plans requirements for coverage have been satisfied. Furthermore, the documentation does not support the medical necessity for an exception to the plans prior authorization requirements.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, a quantity limit exception request, and a reimbursement request for Prolia 60 milligram per milliliter solution to treat the enrollee's 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 all available documentation.Prolia 60 milligram per milliliter solution is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type to treat the same condition on the lower tiers of the plans formulary. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. Additionally, the enrollee's pharmacy claims indicate the drug at issue was filled on January 27, 2023. The next date of fill would be July 26, 2023, as the drug has a quantity limit of 1 milliliter every 180 days. Furthermore, the enrollee's request for reimbursement cannot be allowed. The plan's evidence of coverage outlines the copay amounts for a 30-day supply and a 90-day supply for drugs on the fourth cost-sharing tier. We have determined the amount billed was correct.A physician reviewed the appeal and determined that the requested drug is not eligible for a tiering exception, quantity limit exception, or further reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Lidocaine 5 percent patch to treat left knee osteoarthritis. 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 available documentation. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. 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 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: Favorable

At issue is coverage for Kristalose 10 gram packet to treat hepatic encephalopathy. The Part D plan denied the request for coverage because the drug was not on the plans formulary and the available documentation did not support that the formulary alternative drug, Lactulose oral solution, was tried and failed, or was contraindicated. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The requested drug is not on the plans formulary. To grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed or must be deemed contraindicated. In this case, the prescriber has provided patient-specific clinical rationale as to why the alternative drug on the plans formulary, Lactulose oral solution, would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Specifically, the submitted prescriber statement indicates that the enrollee has tried Lactulose and the drug caused intractable nausea and vomiting. The submitted medical records/progress notes confirm this statement. Therefore, a formulary exception is supported in this case.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 Orgovyx 120 milligram tablet to treat advanced prostate cancer. 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 available documentation.The plan has prior authorization requirements for this drug that must be met before coverage will be provided. These requirements include Orgovyx should be used for advanced disease without radiation. However, the submitted documentation indicates that the enrollee will receive radiation for locally advanced disease. The National Comprehensive Cancer Network includes a 2A recommendation for Orgovyx to be used in initial androgen deprivation therapy (ADT) as a single agent in combination with external beam radiation therapy (EBRT) if life expectancy is greater than five years or symptomatic for patients in the regional risk group (any T, N1, M0). The enrollee has N1 disease based on imaging. Therefore, the documentation supports an exception to the prior authorization requirement(s).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 coverage for Teriparatide 620 microgram per 2.48 milliliter to treat osteoporosis. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all available documentation.The requested drug is not on the plans formulary. To grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed or must be deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale as to why the alternative drugs on the plans formulary to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Additionally, the submitted documentation does not support that the enrollee has tried and failed all of the formulary alternative drugs. Therefore, the formulary exception requirements have not been met.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 coverage for Testosterone Cypionate 200 milligram per milliliter intramuscular solution to treat male hypogonadism. The Part D plan denied the request for coverage. In order for a drug to be covered by Medicare Part D, it must be prescribed for a medically accepted indication outlined in the Medicare approved compendia. The provided diagnosis of male hypogonadism, by itself, if not sufficient to establish that the requested drug has been prescribed for a medically accepted indication outlined in the Medicare approved compendia. During this review, we requested medical records and a prescriber statement to clarify the enrollees diagnosis and to address the plans coverage requirements for the drug. The prescriber did not respond to the request. As such, there is insufficient documentation available to establish that the requested drug has been prescribed for a 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 coverage for Lokelma 10 gram oral powder for suspension to treat hyperkalemia. 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 available documentation.The requested drug is not on the plans formulary. To grant an exception for a drug that is not on the plans formulary, alternative formulary drugs must have been tried and failed or must be deemed contraindicated. In this case, the prescriber has not provided patient-specific clinical rationale as to why the alternative drugs on the plans formulary to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reactions or other harm. Additionally, the submitted documentation does not support that the enrollee has tried and failed all of the formulary alternative drugs. Therefore, the formulary exception requirements have not been met.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 Isosorbide Mononitrate ER (extended release) 30 milligram tablet prescribed for unspecified 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 reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the plan reprocessed claims for the requested drug and adjusted the amount owed due to rework to fill gaps in the enrollees true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ranolazine ER (extended release) 500 milligram tablet prescribed for unspecified 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 reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the plan reprocessed claims for the requested drug and adjusted the amount owed due to rework to fill gaps in the enrollees true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the enrollee is responsible for their share of any deductible and copay that was not applied at the point of sale.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Contour Kit Next EZ. 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. This includes the case file from the plan, and any information submitted at the reconsideration level.The plans 2023 Evidence of Coverage states, reimbursement for drugs is based the total cost of covered drugs, minus the required deductible, copay, or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The item at issue is not on the plan's formulary. The plan has a 20 percent copay for non-formulary drugs. Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Contour Next Test Strips. 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. This includes the case file from the plan, and any information submitted at the reconsideration level.The plans 2023 Evidence of Coverage states, reimbursement for drugs is based the total cost of covered drugs, minus the required deductible, copay, or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The item at issue is not on the plan's formulary. The plan has a 20 percent copay for non-formulary drugs. Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Freestyle MIS Lancets. 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. This includes the case file from the plan, and any information submitted at the reconsideration level.The plans 2023 Evidence of Coverage states, reimbursement for drugs is based the total cost of covered drugs, minus the required deductible, copay, or coinsurance amount, and minus the difference between what the plan approves for the drug and what the pharmacy charges. The item at issue is not on the plan's formulary. The plan has a 20 percent copay for non-formulary drugs. Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Paxlovid 100 milligram tablet. The Part D plan auto-forwarded the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee purchased drugs from a pharmacy on a cruise ship. The submitted documentation does not include a valid National Drug Code for the drug at issue. Without a National Drug Code, it cannot be determined the drug at issue was purchased in the United States. Drugs purchased on a cruise ship are considered foreign claims outside of the United States and are excluded from coverage. Therefore, the requested drug is excluded from coverage and not eligible for reimbursement.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Vivotif Berna injection prescribed for vaccination. The Part D plan denied the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the enrollee received the vaccine at the prescriber's office. The plans Evidence of Coverage states that payment for vaccines including administration fee is required up front from the enrollee when provided at an out of network pharmacy or prescribers office. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The enrollee provided a statement from the prescribers office and a cancelled check indicating full payment was made for the vaccine and administration fee. Therefore, we determined the reimbursement criteria have been met.