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

At issue is Capecitabine 500-milligram tablet to treat malignant neoplasm of rectum and sigmoid colon. The Part D plan denied the request. We performed 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 drug at issue is an oral cancer drug that has the same active ingredient as an injectable drug. Oral cancer drugs that contain the same active ingredient as injectable dosage forms are covered under Medicare Part B. The drug at issue is not considered a Part D benefit.We determined that the plan is not required to cover the Capecitabine .
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Alendronate Sodium 70 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 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 record shows the enrollee is requesting additional reimbursement for the requested drug. 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 plan processed the claim for reimbursement. Reimbursement is calculated based on the total cost of the drug, minus the required coinsurance amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges, In this case, the enrollees cost share was $0 coinsurance. Therefore, no reimbursement is due.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Levothyroxine 150 microgram 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 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 record shows the enrollee is requesting additional reimbursement for the requested drug. 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 plan processed the claim for reimbursement. Reimbursement is calculated based on the total cost of the drug, minus the required coinsurance amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges, In this case, the enrollees cost share of 25 percent was based on the negotiated price at the point of sale. 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 Cabometyx 40-milligram tablets to treat pancreatic adenocarcinoma. 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.Medicare-approved compendia do not contain any citations to support the use of the requested drug as prescribed, for treatment of the noted diagnosis. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.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 Myrbetriq 25-milligrams extended-release tablet to treat an overactive bladder. 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.Myrbetriq 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 Modafinil 100 milligram tablet to treat unspecified hypersomnia. 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.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(s) is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Motegrity 1-milligram tablets to treat chronic idiopathic 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.The requested drug is not on the plans formulary. However, the prescriber has indicated why all alternatives required by the Plan would likely not be as effective as the requested drug for the enrollee, or would likely cause adverse reaction(s) to the enrollee. Therefore, an exception to the Plans coverage criteria is medically necessary. 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 Contrave 8-90-milligram tablets to treat obesity. 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.Drugs prescribed to treat weight gain (promote weight loss) 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 a tiering exception request for Xarelto 20-milligram tablets for thrombosis prophylaxis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we 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 criteria.According to the Plans 2022 formulary, Xarelto 20-milligram tablets 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 Nubeqa 300-milligram tablet to treat metastatic, castration resistant prostate cancer. 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. Medicare-approved compendia do not contain any citations to support the use of the requested drug as prescribed, for treatment of the noted diagnosis. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare.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 Rocklatan 0.02-0.0005-percent ophthalmic solution to treat primary bilateral open-angle glaucoma. 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 medical records and a prescriber statement to support the enrollee has satisfied the plans step therapy requirements. We received additional documentation and included it in the review.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. There were no medical records submitted. The request for a tiering exception was not reviewed. We cannot consider a tiering exception for a drug for which the Part D Plan is unable to provide coverage.A physician reviewer determined that neither step therapy nor step therapy exception criteria are met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Droxidopa 100-milligram capsules to treat orthostatic hypotension, not neurogenic. 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(s) 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 Octreotide Acetate 200-micrograms/milliliter Solution to treat diarrhea secondary to pancreatic insufficiency. 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 tiering exception request for Trelegy Ellipta 100-62.5-25 to treat an unspecified diagnosis. 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.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 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: Favorable

At issue is Kisqali Femara 200-milligram/2.5-milligram therapy pack to treat metastatic HR positive, HER2 negative breast cancer, as initial endocrine-based therapy. 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 Medicare approved compendia contain a citation to support the use of the drug for the noted diagnosis.As such, the submitted documentation supports the drug was prescribed for a medically accepted indication. The submitted documentation supports the enrollee has been on the drug therapy at issue since 2017, and this is a continuation of therapy. The drug at issue was used as initial endocrine-based therapy when first prescribed. The Medicare approved compendia support the use of the drug as initial therapy in post-menopausal women with metastatic HR positive, HER2 negative breast cancer. An exception to the plan's prior authorization coverage criteria 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 Testosterone 12.5-milligram per actuation (1-percent) gel pump to treat hypogonadism. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we 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 the prescriber to provide supporting medical documentation to confirm the diagnosis related to the requested drug. We also requested documentation to support that the enrollee has satisfied the plans prior authorization coverage criteria. However, we did not receive the requested information.Upon the redetermination, the plan denied the appeal request stating the prior authorization criteria was not met. However, no medical records have been provided to determine if this enrollee has met the criteria for a medically acceptable indication per the approved Medicare compendia. Therefore, the drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Wegovy Auto-injector 2.4-milligrams/0.75-milliliter solution to treat obesity 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 reviewed all documentation submitted including the case file from the plan and any information submitted at the reconsideration level.Drugs prescribed to treat weight gain (promote weight loss) are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

Temazepam 15 milligram capsule was requested to treat the enrollees condition. The case was auto-forwarded by the plan.  As well, the requested drug has prior authorization criteria. We received an expedited reconsideration 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.A request was submitted to the prescriber to provide a diagnosis, address the prior authorization criteria and to provide supporting medical records.  A reply from the prescriber was not received. Without a diagnosis, it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Dexilant 60-milligram capsules to treat severe acidreflux and heartburn. 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.Dexilant is a brand drug on Tier 4 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 a tiering exception request for Horizant 300-milligram tablets to treat restless leg syndrome. 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 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 reviewer determined that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Freestyle Libre 14 day sensor prescribed for diabetes mellitus type 2 with 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. Supplies for testing and monitoring blood glucose levels are not considered Part D drugs and may be covered under the Medicare Part B durable medical equipment benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha SureClick 140-milligrams/milliliter to treat atherosclerotic heart disease of native coronary artery, hyperlipidemia, and occlusion and stenosis of bilateral carotid arteries. 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 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 a tiering exception request for Esomeprazole Magnesium DR 40-milligram delayed release capsules to treat gastroesophageal reflux 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. During this review, we requested documentation from the prescriber to support that all lower-tier drugs to treat the enrollees condition were tried and failed or were contraindicated. The prescriber responded and the additional documentation has been included it in the review.Esomeprazole Magnesium DR is a generic drug on Tier 2 of the plans formulary. The prescriber has not addressed all drugs of the same type on the lower tier of the plans formulary to treat the enrollees condition. 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.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Deferasirox 360-milligram tablet to treat macrocytic anemia and hemachromatosis due to multiple blood infusions. 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 diagnosis of hemachromatosis due to multiple blood infusions is transfusion hemosiderosis, which is a medically approved indication. The documentation satisfies the plans coverage criteria. The records indicate the enrollees ferritin level was elevated greater than the required baseline and the enrollee has required multiple packed red blood cell transfusions.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 a tiering exception request for Zejula 100-milligram capsule for maintenance treatment of ovarian cancer. 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 Specialy 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 Enbrel Sureclick 50-milligram/milliliter to treat ankylosing spondylitis/peripheral spondyloarthropathy. 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 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 Pepcid AC 20-milligram tablets prescribed for gastroesophageal reflux disease. 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.Pepcid AC 20-milligram tablets are available over the counter without a prescription. Nonprescription drugs, even when a prescription has been written, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.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.