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

At issue is Nystatin 100,000-units/gram Powder to treat perspiration. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. The case was auto-forwarded by the plan.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 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 condition. 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

You requested Lidocaine 5 percent patches prescribed as directed for abdominal wall pain. The Part D plan denied your request. We performed 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 also researched Medicare systems and reviewed the enrollment data available. At initial determination and redetermination the diagnosis of abdominal wall pain was given. At reconsideration a diagnosis of chest wall pain was given. The use of the requested drug to treat the provided diagnoses 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 these conditions.  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 Lidocaine 5 percent patches.
Appeal type: Prescription Drug
Decision: Favorable

You requested Venclexta 100 milligram tablet prescribed for newly diagnosed acute myeloid leukemia. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We asked the prescriber to send us additional medical records to support necessity. We received the documentation and included it in our review.The record shows you have newly diagnosed acute myeloid leukemia and are to be treated with Venclexta in combination with Decitabine. The records indicate that you are 74 years old and are too weak for induction therapy. The National Comprehensive Cancer Network recommends treatment of newly diagnosed acute myeloid leukemia with Venclexta and Decitabine in an enrollee above age 60 who is not a candidate for intensive induction therapy. Therefore, an exception to the prior authorization criteria can be made.An oncologist reviewed your appeal and determined that the plan is required to cover Venclexta 100 milligram tablet.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Alimta 500 milligram injectable prescribed for recurrent, metastatic non-squamous lung cancer in combination with Carboplatin. 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 asked for 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 medical records show you prescribed Alimta in combination with Carboplatin to treat the enrollees recurrent, metastatic non-squamous lung cancer. According to the National Comprehensive Cancer Network, a Medicare approved compendium, this is a medically accepted indication. Your plan also has prior authorization requirements for this drug that must be met before they will cover the requested drug. The provider has indicated that this medication will be brown bagged to the physicians office and will not come from their stock. The documentation provided does show the enrollee has satisfied the plan's coverage criteria.An oncologist reviewed your appeal and determined that the plan is required to cover Alimta 500 milligram injectable.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Inlyta 5 milligram tablet prescribed for metastatic mucosal melanoma. 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 information submitted at the reconsideration level.The records show you prescribed Inlyta 5 milligram tablet to treat the enrollees metastatic mucosal melanoma. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Inlyta 5 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsule prescribed daily for non 24-hour sleep/wake cycle. 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 all documentation submitted. This includes any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.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 did not receive the documentation requested.Hetlioz was prescribed to treat your non 24-hour sleep/wake cycle. 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 you have satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Hetlioz. 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 Tyvaso 1.74 milligram per 2.9 milliliter Refill Kit prescribed for pulmonary arterial hypertension, WHO Group I. 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 to show why need the medication was needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. We received the documentation and included it in our review.The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary alternatives required by the plan would likely not be as effective as the requested drug for this condition, and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported. There are alternative medications on the formulary that have different mechanisms of action than those currently in use. In this case, the medical records do not support why other drugs on the plans formulary would not work. A physician reviewed your appeal and determined that the plan is not required to cover Tyvaso.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xiidra 5% solution prescribed twice daily for dry eye 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 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 asked the prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. We received the documentation and included it in our review.The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan 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 formulary coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.A physician reviewed your appeal and determined that the plan is not required to cover Xiidra 5% solution.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested compounded drug Sodium hyaluronate  prednisolone eye drops prescribed for unknown diagnosis. 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 information submitted at the reconsideration level.The plan denied your request for reimbursement because valid National Drug Codes were not provided for some of the ingredients of the compounded drug. We verified the National Drug Codes with the Food and Drug Administration. The numbers were invalid and therefore, not eligible for coverage or under Medicare Part D.  We determined the plan is not required to provide additional reimbursement for the Sodium hyaluronate-prednisolone eye drops.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement of Omeprazole Delayed Release Capsules. We received an auto-forwarded reconsideration request from the coverage level.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 also researched Medicare systems and reviewed the enrollment data available. A request was sent to your prescriber for additional information including the diagnosis that the drug is being prescribed for. We have not received a response. The documentation was insufficient to determine if the drug is prescribed for a medically accepted indication and if the drug is eligible for Part D coverage.  A physician reviewed your appeal and determined that the plan is not required to cover reimbursement of Omeprazole Capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Calcipotriene 0.005% ointment prescribed for psoriasis. 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 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 a prescriber statement. Your doctor prescribed Calcipotriene to treat psoriasis. 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 your appeal and determined that the plan is not required to Calcipotriene. 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 Immunoglobulin 10-milligrams/milliliter intravenous to treat toxic polyneuropathy and Velcade-induced radiculoneuropathy. The Part D plan denied the request stating that the provided diagnoses are non-medically accepted indication. 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 use of the requested drug to treat the provided diagnoses are 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 these conditions. 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 prescribed Lidocaine-Prilocaine 2.5/2.5% cream. 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.Your medical records show your doctor prescribed the Lidocaine-Prilocaine cream to treat your pain in the left foot, neuropathic pain, and other spondylosis with radiculopathy, lumbar region. The use of the requested drug to treat the provided diagnoses 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 these conditions.  Therefore, the requested drug, as ordered, is not being used for a medically accepted indication. 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 Lidocaine-Prilocaine cream.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycontin Extended Release 80 milligram tablets prescribed to treat neck and back pain. 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 information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. The plan requires prior authorization requirements be met before covering this drug. The documentation submitted does not include medical records supporting the prior pain medications/therapies tried and non-opioid therapies had been optimized and are being used in conjunction with opioid therapy. There is no indication the prescribing physician has checked the patients history of controlled substance prescriptions using the state prescription drug monitoring program or has a treatment plan (including goals for pain and function) in place. Patients with cancer, sickle cell disease, in hospice or who reside in a long term care facility are not required to meet this criteria. The prior authorization requirements have not been met. A physician reviewed your appeal and determined that the plan is not required to cover Oxycontin Extended Release tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Acetaminophen 500 milligram tablets administered while hospitalized. The Part D plan denied your request.We performed 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 Acetaminophen because it is an over-the-counter product. Nonprescription, or over-the-counter drugs, are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that reimbursement cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Aspirin EC 81 milligram tablets administered while hospitalized. The Part D plan denied your request.We performed 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 Aspirin because it is an over-the-counter product. Nonprescription, or over-the-counter drugs, are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that reimbursement cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Testosterone 1.62% gel prescribed for unknown diagnosis. 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 information submitted at the reconsideration level.The plan submitted documentation that shows you were still in the deductible stage for part of the cost for this drug and entered the initial stage for the remaining amount. You are responsible for the full cost of covered drugs until the deductible amount is satisfied. After the deductible was met, the plan calculated reimbursement based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charged you. We determined the Testosterone was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Shingrix prescribed for shingles vaccination. The Part D plan was unable to review your case timely and auto-forwarded 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 information submitted at the reconsideration level.The record shows you received the Shingrix vaccination at your physicians office. According to your plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus your required co-payment amount, and the difference between what the plan normally pays for the drug and what the out-of-network physicians office charged you. If you pay the full cost of a prescription, then you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, you did not provide proof of payment for the vaccine and its administration in the form of a receipt. Therefore, we determined that the plan is not required to reimburse you. Please submit proof of payment to your plan for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Flonase allergy relief spray 50 micro grams, quantity of 3 bottles for unknown diagnosis.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, over-the-counter drugs are excluded from coverage under Part D. Therefore, we determined that the plan is not required to reimburse you for the Flonase allergy relief spray.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metoprolol Succinate 50 milligram extended-release oral tablet prescribed daily for atrial flutter. The Part D plan auto-forwarded the case.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. We asked your prescriber to send us information about your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why similar medications on the lower tiers would not work for you. Metoprolol Succinate is a generic drug on Tier 2 of the plans formulary. The medical records do not support that all drugs available on lower tiers to treat your condition have been tried or deemed contraindicated. 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 Jardiance 25 milligram tablets prescribed for the enrollees condition. 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. Jardiance is a brand name drug on Tier 3 of the plans formulary. There are no brand name 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 coverage for Testosterone 1.62% gel prescribed for hypogonadism. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we 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 submitted 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 validated 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 Chlorzoxazone 375-milligram tablet to treat acute musculoskeletal pain. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 record shows you were prescribed Chlorzoxazone. We asked the prescriber to send us a prescriber statement, diagnosis, and medical records. However, we did not receive the documentation. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan 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 formulary coverage criteria is not supported.Our physician reviewer's opinion is that formulary exception criteria are not met.