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

At issue is a request for coverage of Benzonatate 100 milligram capsules. 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 that Benzonatate has been prescribed for cough relief. However, drugs when used for the symptomatic relief of cough are excluded from coverage under Medicare Part D. Therefore, the Benzonatate is not eligible for coverage under Medicare Part D. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Epolamine 1.3% patch prescribed to treat acute right ankle pain due to a major sprain. 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 documentation shows the doctor prescribed Diclofenac Epolamine 1.3% patch to treat acute right ankle pain due to a major sprain. DRUGDEX, a Medicare approved compendium states, Diclofenac Epolamine 1.3% patch topical system is indicated for topical treatment of acute pain due to minor strains, sprains and contusions in adult patients. Therefore, the Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed your appeal and determined that the plan is not required to cover Diclofenac Epolamine 1.3% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ethyl Alcohol 100% solution for onychomycosis. 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 the Ethyl Alcohol 100% solution is part of a compounded drug and each ingredient is reviewed individually. Medicare Part D does not cover drugs that do not meet the definition of a Part D drug. None of the ingredients within the compounded drug are eligible for Part D coverage. Therefore, we determined that the plan is not required to cover or reimburse for the Ethyl Alcohol 100% solution compounded drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Thymol crystals for onychomycosis. 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 the Thymol crystals is part of a compounded drug and each ingredient is reviewed individually. Medicare Part D does not cover drugs that do not meet the definition of a Part D drug. None of the ingredients within the compounded drug are eligible for Part D coverage. Therefore, we determined that the plan is not required to cover or reimburse for the Thymol crystals compounded drug.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a formulary exception request for Dupixent 300 milligram/2 milliliter pen injector prescribed for bullous pemphigoid. 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.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 why other medications on the plan's formulary would not work for the enrollee. We received the documentation and included it in the review.The medical records show the physician prescribed Dupixent for bullous pemphigoid. The Medicare approved compendia indicate the drug at issue has an orphan drug designation for the condition.The records show that you cannot take other drugs on your plans formulary for your condition. Specifically, the enrollee was diagnosed with latent tuberculosis. The formulary alternatives, Methotrexate and Mycophenolate Mofetil, are immunosuppressant medication and would be contraindicated for the enrollee.A physician reviewed your appeal and determined that an exception can be granted to cover the drug that is not on your plans formulary. Therefore, the plan is required to cover Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rexulti 0.5 milligram tablet prescribed daily for bipolar type 1 disorder and borderline personality disorder. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The doctor prescribed Rexulti to treat the enrollees bipolar type 1 disorder and borderline personality disorder. However, the Medicare approved compendia do not support the use of this drug for these conditions. A physician reviewed the appeal and determined that the plan is not required to cover Rexulti.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methocarbamol 500 milligram tablet prescribed for other muscle spasm. 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 submitted documentation indicates the prescriber ordered Methocarbamol for other muscle spasm. There are no medical records to indicate the muscle spasms are due to an acute musculoskeletal condition. The prescriber stated that the expected length of therapy is 6 months.  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 Contrave 8-90-milligram Extended Release 12-Hour tablet to treat morbid (severe) obesity due to excess calories.   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.Drugs prescribed for the treatment of weight loss are excluded from coverage. Therefore, this drug is excluded from coverage.A physician reviewed the appeal and determined that the requested drug is excluded from Medicare Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch prescribed for bilateral shoulder osteoarthritis. 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 submitted documentation indicates the prescriber ordered Lidocaine 5% patch for bilateral shoulder osteoarthritis. 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 quantity limit exception request for Dextroamphetamine-Amphetamine 30 milligram capsules, 150 capsules per 30 days, prescribed for attention deficit hyperactivity disorder. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.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 amount of the medication. We did not receive the documentation requested.The documentation submitted shows the prescriber ordered the drug at issue for attention deficit hyperactivity disorder at a quantity of 150 capsules per 30 days. However, the records do not support why an exception to the plans quantity limit of 60 capsules per 30 days is medically necessary. A physician reviewed your appeal and determined that the plan is not required to cover the Dextroamphetamine-Amphetamine, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Spiriva CAP Handihaler 18 microgram prescribed daily for unknown diagnosis. The Part D plan denied the request.  We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows the enrollee purchased Spiriva CAP Handihaler from a network pharmacy for an amount that is less than or equal to the required coinsurance and copayment amount. We reviewed the plans formulary and Evidence of Coverage. In this case, the documentation shows the enrollee was in the coverage gap stage when the Spiriva CAP Handihaler was purchased. The plan paid its share of the cost for the covered drug and the enrollee was responsible for their share of the remaining 25%. We determined that the plan is not required to provide additional reimbursement for the Spiriva CAP Handihaler.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Premarin 0.625 milligram tablet prescribed daily for menopausal and female climacteric states. 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 medical records do not support why other drugs on the plans formulary would not work for you.A physician reviewed the appeal and determined that the plan is not required to cover Premarin.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Tacrolimus 5 milligram capsule prescribed daily to prevent rejection from kidney transplant status. 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. We determined that the plan is not required to cover the Tacrolimus. Medicare records indicate the enrollee received a kidney transplant on September 30, 2020, which was covered by Medicare Part A. Therefore, the transplant is considered a Medicare covered transplant and Tacrolimus is eligible under Medicare Part B. Medicare rules state that a drug covered under Part B cannot be covered under Part D. 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 initial determination, Cyclobenzaprine HCL 10 milligram tablet was prescribed for cervicalgia and myalgia. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.We asked the 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 did not receive the documentation requested. At reconsideration, Cyclobenzaprine HCL was prescribed to treat cervicalgia and muscle spasm. No medical records were provided to validate a change in diagnosis and establish a medically accepted indication.A physician reviewed your appeal and determined that the plan is not required to cover Cyclobenzaprine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregabalin 100 milligram capsules prescribed for the enrollees condition. 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.Pregabalin is a generic drug on Tier 3 of the plans formulary. The prescriber submitted a supporting statement. The supporting statement did not address why all the drugs available on the lower tiers of the plans formulary would not work. 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 Linezolid 600 milligram tablet prescribed twice daily for vancomycin sensitive enterococcus faecium urinary tract infection. 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 Linezolid to treat the enrollees vancomycin sensitive urinary tract infection. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Linezolid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Shingrix 50 microgram/0.5 milliliter intramuscular suspension kit. 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 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. Shingrix is a biologic drug on Tier 4 of the plans formulary. There are no biologic drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mavenclad 10 milligrams pack (8 tablets per pack) prescribed to treat multiple sclerosis. 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.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work the enrollee.A physician reviewed the appeal and determined that the plan is not required to cover Mavenclad 10 milligrams pack (8 tablets per pack).
Appeal type: Prescription Drug
Decision: Favorable

At issue is Timolol Maleate  0.5% solution prescribed for glaucoma. The Part D plan denied the request because the drug is not included on the plan's formulary.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 Timolol Maleate is a generic drug on Tier #1 of the plan's formulary. DrugDex, a Medicare approved compendium, supports the use of Timolol Maleate for the treatment of glaucoma.A physician reviewed your appeal and determined that the plan is required to cover Timolol Maleate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Anusol-HC 25 milligram suppositories prescribed for second-degree hemorrhoids. 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. Anusol-HC is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. During this review, a request was submitted to the prescriber to address the alternative medications included in the plans formulary and to provide supporting medical records. The prescriber did not respond to the request. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Neupro 1 milligram per 24 hour transdermal patch prescribed for restless leg syndrome. 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. Neupro is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives included in the plan to treat the noted condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Sildenafil 100 milligram tablet prescribed for erectile dysfunction. 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 record shows that Sildenafil was prescribed to the enrollee for use to treat sexual or erectile dysfunction. We determined that the plan is not required to cover the Sildenafil. Medicare excludes certain drugs from Part D coverage. Sildenafil is an excluded drug when used to treat sexual or erectile dysfunction; or to treat a condition other than sexual or erectile dysfunction for which the drug has not been approved by the Food and Drug Administration. The record does not indicate that the plan provides supplemental coverage for Sildenafil. Therefore, the plan is not required to cover it. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.In conclusion, our decision is unfavorable.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trelegy Ellipta 100-62.5-25 micrograms per actuation prescribed two per day for chronic obstructive pulmonary disease. 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. Trelegy Ellipta 100-62.5-25 micrograms per actuation 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 Dronabinol 2.5 milligram capsules prescribed to treat weight loss due to end-stage emphysema. 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 documentation shows the doctor prescribed Dronabinol 2.5 milligram capsules to treat weight loss due to end-stage emphysema. 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 Dronabinol 2.5 milligram capsules.
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 your appeal and determined that the requested drug is not eligible for coverage under Medicare Part D.