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

At issue is Budesonide enteric coated 3 milligram capsules initially prescribed to treat an enrollee with unspecified noninfective gastroenteritis and colitis, steroid-resistant CMV colitis, and intestinal ulcers. 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 Budesonide enteric coated 3 milligram capsules. Upon reconsideration, the doctor indicates the enrollee has a diagnosis of possible Crohns disease with lower abdominal pain. However, there are no medical records provided to support this diagnosis. 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 Budesonide enteric coated 3 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gabapentin powder prescribed to treat neuropathic 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 Gabapentin powder was prescribed. The requested compound drug contains bulk powder ingredients. 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 Ferosul 325 milligram tablets prescribed for iron deficiency anemia due to chronic blood loss. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We determined that the plan is not required to cover Ferosul because it is an over-the-counter drug. Nonprescription or over-the-counter drugs are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dexcom G6 device. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The drug at issue is a medical device. This is eligible for coverage under Part B. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Alli 60 milligram capsules prescribed to treat obesity. 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 information submitted at the reconsideration level.The record shows the doctor prescribed Alli 60 milligram capsules to treat obesity. We determined the plan is not required to cover Alli 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 Shingrix 50 micrograms per 0.5 milliliters injection. The Part D plan denied your 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.Shingrix is a biological drug on Tier 3 of the plans formulary. There are no biological drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no biological 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 grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Verquvo 10 milligram tablets prescribed for chronic systolic heart failure. 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.For a drug to be considered eligible for coverage under Medicare Part D, the claim must be submitted with the correct National Drug Code (NDC) number for that drug which has been registered with the Food and Drug Administration. This claim has been submitted with an invalid National Drug Code number. 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 without a valid National Drug Code nubmer. Please resubmit the request to the Part D plan with the correct National Drug Code number.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tacrolimus 0.5 milligram capsules prescribed for graft versus host disease. 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 also researched Medicare systems and reviewed the enrollment data available. Based on the information provided, the drug is eligible for Part B coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prednisone 10 milligram tablets prescribed daily following a kidney transplant. 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 also researched Medicare systems and reviewed the enrollment data available. Based on the information provided, the drug is eligible for Part B coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Ensure liquid 1 can prescribed twice daily for protein calorie malnutrition. 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 read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. 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 this medication. We received the documentation and included it in our review.The medical records show Ensure was prescribed to treat protein calorie malnutrition. 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 your appeal and determined that the plan is not required to cover Ensure. 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 Diclofenac Sodium 3% gel prescribed to treat an enrollee with idiopathic osteoarthritis. The Part D plan denied the appeal request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows the doctor prescribed Diclofenac Sodium 3% gel to treat idiopathic osteoarthritis. 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 Diclofenac Sodium 3% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tremfya 100 milligram/milliliter pen injector prescribed for psoriasis vulgaris. 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.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 submitted did not indicate why other drugs on the plans formulary would not work for the enrollee. A physician reviewed the appeal and determined that the plan is not required to cover Tremfya.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Meclizine 25 milligram tablets. The Part D plan denied the request for coverage because the prescriber did not document the indication for the continued use of the drug and that the benefit outweighs the potential risk.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 Meclizine has been prescribed for the treatment of vertigo, which is a medically accepted indication outlined in the Medicare approved compendia. At reconsideration, the prescriber has submitted documentation that acknowledges the enrollee is taking multiple anticholinergic and/or central nervous system active medications (Meclizine and Orphenadrine) and attests the benefit of continuing these medications together outweighs the risk of increased adverse outcomes. Additionally, the documentation attests that the prescriber has provided education to the enrollee regarding these drugs. Therefore, the documentation submitted at reconsideration satisfies this coverage requirement. The plan has no other coverage requirements for Meclizine and the drug is being prescribed for a medically accepted indication. Therefore, coverage for the drug 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 Alimta 500 milligram injection prescribed for non-small cell lung cancer. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The drug is being supplied by the physician. This is eligible for coverage under Part B. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Desvenlafaxine tablets prescribed for depression. 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. Desvenlafaxine has been approved 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 a lower-cost tiering exception for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Acitretin 25 milligram capsules prescribed for the treatment of severe palmoplantar 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 a request for coverage of Dronabinol 10 milligram capsules. 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 Dronabinol has been prescribed for the treatment of poor appetite and chronic nausea in an enrollee who does not have acquired immunodeficiency syndrome or is not receiving chemotherapy. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for 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 Buprenorphine Hydrochloride 8 milligram sublingual tablets prescribed for chronic pain. 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 submitted documentation does not indicate that Buprenorphine Hydrochloride sublingual tablet was a part of the treatment plan for opioid dependence.  Therefore, the enrollee does not satisfy the Plan's coverage criteria A physician reviewed the appeal and determined that the plan is not required to cover Buprenorphine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Lidocaine 5% patches. The Part D plan denied the request stating that the drug was being used for a non-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.The use of Lidocaine 5% patches for the treatment of chronic pain not related to low back pain or knee or hip osteoarthritis pain is not a medically accepted indication outlined in the Medicare approved compendia.  Furthermore, at reconsideration, the documentation included an additional diagnosis of diabetic peripheral neuropathy.  A request was submitted to the prescriber to provide medical records to validate the diagnosis of diabetic neuropathy. However, no medical records were submitted to confirm the diagnosis. Therefore, there is insufficient evidence to determine if the requested drug is being prescribed for a medically accepted indication. As such, the requested drug is not eligible for coverage under Medicare Part D.  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 Otezla 30 milligram tablets prescribed for oral lichen planus. 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 indicates the prescriber ordered Otezla for oral lichen planus. 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 Otezla.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Spravato 56 milligram spray prescribed for treatment resistant depression. 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 record shows Spravato is being prescribed to the enrollee for treatment resistant depression. Medicare law specifically excludes coverage for any drug for which payment would be available under Medicare Parts A or B for that individual. Medicare Part B pays for services and supplies incident to the service of a physician (or other practitioner). Spravato is a type of drug that must be administered under direct observation of a health care provider and monitored for at least two hours after administration. The Food and Drug Administration has mandated a Risk Evaluation and Mitigation Strategy for Spravato. This strategy requires that Spravato be only dispensed and administered to patients in a medically supervised healthcare setting that monitors the enrollee. We determined that the drug is eligible under Medicare Part B. Therefore, the Part D plan is not required to cover Spravato. 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 is a request for coverage of Cresemba 186 milligram capsules. 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 Cresemba has been prescribed for antifungal prophylaxis in an enrollee with acute myeloid leukemia who had a recent stem cell transplant and is on a high-dose steroid regimen. However, the Medicare approved compendia do not contain any citations to support the use of Cresemba for antifungal prophylaxis. 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 Myrbetriq 25 milligram tablets prescribed for overactive bladder. 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.Myrbetriq 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

At issue is Febuxostat 40 milligram tablets prescribed for gout. 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.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 submitted did not indicate why other drugs on the plans formulary would not work for the enrollee. A physician reviewed the appeal and determined that the plan is not required to cover Febuxostat.