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

At issue is Diclofenac Epolamine 1.3% patch prescribed for knee swelling. 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 the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs the medication. Specifically, we asked for records to show if the drug is to be used for acute pain due to minor strain, sprain, or contusion. However, we did not receive the documentation.The submitted documentation indicates the prescriber ordered Diclofenac Epolamine patch for knee swelling. The prescriber stated that the enrollee has been using the requested drug for, 'over 15 years.'  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 request for coverage of Otezla 30 milligram tablets prescribed for moderate to severe plaque psoriasis. 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 sufficiently addressed 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 Breztri aerosphere aerosol 160-9-4.8 microgram/actuation prescribed for 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. 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 prescribers statement and medical records do not support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Breztri.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Androgel 1% (50 milligram/5 gram) packet was prescribed for male hypogonadism. 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 information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We received the documentation and included it in our review.The documentation shows Androgel was prescribed to treat male hypogonadism. However, the Medicare approved compendia note that: The safety and efficacy of testosterone therapy have not been established in men with late-onset (age-related) hypogonadism. Medical records have not been provided to establish the diagnosis of primary hypogonadism.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 Prolia 60 milligram/milliliter syringe prescribed one injection every 6 months for age-related osteoporosis. 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. The documentation shows the doctor prescribed Prolia to treat the enrollees age-related osteoporosis. The plan has step therapy 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 Prolia. Our physician reviewer's opinion is that neither step therapy nor step therapy exception criteria are met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Repatha SureClick 140 milligram per milliliter subcutaneous injection pens prescribed for the treatment of hyperlipidemia in the presence of atherosclerotic cardiovascular disease.   The Part D plan denied the request.  We received a reconsideration 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.  In the Reconsideration appeal dated 7/23/2021, the prescriber provided medical records and a prescriber statement.  The documentation satisfies the plans coverage criteria.  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 Zolpidem Tartrate 12.5 milligram extended-release tablets prescribed to treat insomnia. The Part D plan denied the appeal request.The QIC 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.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication is needed.The documentation shows the doctor prescribed Zolpidem Tartrate 12.5 milligram extended-release tablets to treat insomnia. The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed 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: Favorable

At issue is a request for coverage of Revlimid 10 milligram capsules prescribed for the treatment of folliculotropic mycosis fungoides. The Part D plan denied the request stating the prior authorization requirements were not met, as the documentation did not support the Revlimid was going to be used in combination with Rituxan for the treatment of follicular lymphoma.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.While the plans denial reason states the enrollee is being treated for follicular lymphoma, the submitted medical records and prescriber statement indicate that the Revlimid is being requested to treat folliculotropic mycosis fungoides, which is a type of mycosis fungoides, also known as cutaneous T cell lymphoma. The prescriber has submitted an article from the peer-reviewed Medicare approved journal, Blood titled, Results of Open Label Multicenter Phase 2 Trial of Lenalidomide (Revlimid) Monotherapy in Refractory Mycosis Fungoides. This article involves a trial that included patients who had at least stage 1B disease (skin lesions are covering face and neck and ears, which is 10% of body per physical exam notes) and who had failed at least one line of topical or systemic therapy. The medical records support that the enrollee has met these criteria. In the study, Revlimid showed activity in these patients that had refractory disease and was well tolerated. Therefore, the submitted peer-reviewed Medicare approved journal supports that the drug is being prescribed for a medically accepted indication.In summary, the drug is being used for a medically accepted indication. Additionally, the plans prior authorization requirements do not apply to the enrollees condition. Therefore, an exception to the plans diagnosis-specific prior authorization requirements can be allowed. Finally, the plan has a quantity limit for Revlimid of one capsule daily. The prescriber is requesting one capsule to be taken daily for 21 days then seven days off. Therefore, the plans quantity limit has not been exceeded. A physician reviewed the appeal and determined that the plan is required to cover the Revlimid in this case.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Pulmicort Flexhaler 180 microgram inhalant. 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 levelThe submitted documentation did not include medical records or a prescriber supporting statement. A request for information was sent to the prescriber; however, no further documentation was received. As it cannot be determined that the drug was 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: Favorable

At issue is a prior authorization request for Armodafinil 150 milligram tablets prescribed for multiple sclerosis related fatigue and obstructive sleep apnea. 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. The enrollee satisfies the plan's coverage criteria. The prescriber submitted a statement and medical records to support the enrollee has obstructive sleep apnea. The records include a polysomnography report from date of service 7/1/2019 to corroborate the diagnosis of obstructive sleep apnea. Furthermore, the enrollee also has a diagnosis of fatigue related to multiple sclerosis. The Medicare approved compendium contains a citation to support the use of the drug at issue for this condition.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 Tadalafil 10 milligram tablet prescribed daily for enlarged prostate. 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 doctor prescribed Tadalafil to treat the enrollees enlarged prostate. At reconsideration a diagnosis of benign prostatic hyperplasia was given. Medical records were requested.  However, no medical records were provided by the prescriber to support this diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. A physician reviewed the appeal and determined that the plan is not required to cover Tadalafil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Fluticasone Propionate-Salmeterol 250-50 microgram (0.25-0.05 milligram) inhalation powder. 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. Fluticasone-Salmeterol is a generic drug on Tier 3 of the plans formulary. There are no generic drugs of the same type on the lower cost sharing tiers. If there are no generic drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Corlanor 5 milligram tablet prescribed twice daily for heart failure. 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. The medical records show your doctor prescribed Corlanor 5 milligram to treat the enrollees heart failure. Your 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 Corlanor 5 milligram. 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 a request for coverage of Prolia 60 milligram per milliliter subcutaneous injection syringe prescribed for the treatment of postmenopausal 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 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 sufficiently addressed 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: Favorable

At issue is Retacrit 3,000 units prescribed three times per week for anemia associated with chronic kidney disease in a patient not on dialysis. 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.The medical records show the doctor prescribed Retacrit to treat the enrollees anemia associated with chronic kidney disease. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The records show the enrollee had a kidney transplant on July 20, 2021, and is no longer on dialysis. Laboratory tests and physicians statement support diagnosis of anemia. The documentation provided shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed the appeal and determined that the plan is required to cover Retacrit.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Trikafta 100-50-75 milligram/150 milligram tablets prescribed for cystic fibrosis. The Part D plan denied the request for coverage. We received a reconsideration 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. Additionally, the prescribers office was contacted on July 26, 2021, Clarisa Renteria, RN provided diagnostic testing results from the patients medical record. The patient has cystic fibrosis with genotype F508del/W1282X, and is status post lung transplant. Most recent imaging including CT scan of abdomen and ultrasound showed no evidence of ascites, no evidence of portal hypertension. Laboratory studies demonstrated bilirubin of 0.5, albumin of 4.2, prothrombin time of 12.2, INR of 1.0. Office note is without indication of encephalopathy. Calculated Child-Pugh score is 6, Child-Pugh classification A.The documentation satisfies the plans coverage criteria.  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 Aranesp (Albumen Free) 60-micrograms/0.3milliliter Solution Prefilled Syringe to treat anemia associated with chronic kidney disease in an enrollee not on dialysis. 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.  In the Reconsideration appeal the prescriber submitted medical records and a prescriber statement.  The enrollee's hemoglobin on 7/9/2021 was 8.0 grams per deciliter.The documentation satisfies the plans coverage criteria. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At determination and redetermination, Sunosi 75 milligram tablet prescribed for somnolence, unspecified. The Part D plan denied the request because the drug was not prescribed for a medically accepted indication.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. At redetermination, the diagnosis of hypersomnolence and obstructive sleep apnea and secondary narcolepsy is given. The medical record present does not provide sufficient support, by the medically appropriate diagnostic testing, to validate this change in diagnosis. A medically accepted indication can not be established.A physician reviewed your appeal and determined that the plan is not required to cover Sunosi.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20-milligram capsule to treat circadian rhythm sleep disorder, free running type (Non-24). The 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 documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed 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 Zolpidem 10-milligram tablet to treat insomnia. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. This drug is considered a high-risk medication in older enrollees. We received a reconsideration 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 documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed, with support of medical records, the issues regarding this high-risk medication, and why alternative safer medications, in the plan's formulary, could not be used. 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 Eliquis 2.5 milligram tablet prescribed twice daily for paroxysmal 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.Eliquis 2.5 milligram tablet is a brand drug on Tier 3 of the plans formulary. There are no brand 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

The enrollee requested Salicylic Acid 27.5 % liquid film prescribed 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.According to Medicare rules, drugs that are not approved by the Food and Drug Administration are excluded from coverage under Part D. Salicylic Acid 27.5 % liquid film has not been approved by the Food and Drug Administration to be safe and effective. Therefore, we determined that the plan is not required to cover the Salicylic Acid. If you purchased drugs/products that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug/product. It only establishes 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 Benlysta 200 milligram per milliliter subcutaneous auto injection pen prescribed for the treatment of systemic lupus erythematosus. 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 sufficiently addressed 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.