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

At issue is a request for coverage of Lidocaine 5% ointment, 150 grams per 30-day supply. The Part D plan denied the request stating that the drug was being used for a non-medically accepted indication. Additionally, the amount of Lidocaine ointment requested exceeded the plans quantity limit for this drug.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% ointment 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. However, the Medicare approved compendium, DrugDex, references an article published by the Journal of the American Medical Association titled, Krebs EE, Gravely A, Nugent S, et al: Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: The SPACE randomized clinical trial. The article involved a study of patients with chronic back pain or hip or knee osteoarthritis pain and found that treatment with opioids compared with nonopioid medications did not result in significantly better pain relief function over 12 months. Nonopioid treatment, such as Lidocaine, was associated with significantly better pain intensity (i.e. less pain).The submitted medical records indicate that the enrollee has chronic back pain and chronic osteoarthritis pain of the right hip, in addition to other areas of chronic pain. However, the study noted above to support the use of nonopioid medications, such as Lidocaine, for the treatment of chronic back pain or hip or knee osteoarthritis pain did not include patients that had active substance use disorder. This group was excluded from the study. The prescriber has indicated that the enrollee does have an active substance abuse disorder and has had previous controlled substance contract violations. Since patients with active substance use disorders were excluded from the study, the enrollee does not meet the same requirements as the participants in the study. Therefore, the study results are not applicable to this enrollee. As such, the requested drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. Since the drug is not eligible for coverage, the quantity being requested is no longer an issue. 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 Zolpidem Tartrate 10 milligrams prescribed daily for primary insomnia. 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.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.The doctor prescribed Zolpidem Tartrate to treat the enrollees primary insomnia. 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 the appeal and determined that the plan is not required to cover Zolpidem Tartrate. 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

The enrollee requested Euflexxa Intra-Articular Solution PREF SYR 20 milligram/2 milliliter 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. We determined that the plan is not required to cover the Euflexxa. Euflexxa is considered a medical device by the Food and Drug Administration and is excluded from coverage under the Medicare Part D drug benefit. The decision does not address medical necessity of the device. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rocklatan 0.02%-0.005% solution. The Part D plan denied the appeal 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.The requested drug is provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.A physician 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 Tacrolimus 0.3% topical gel prescribed for unspecified dermatitis of the eyelid. 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 Tacrolimus 0.3% topical gel for unspecified dermatitis of the eyelid. 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 Spiriva Handihaler Capsule 18-microgram capsule to treat pneumonitis due to inhalation of food and vomit. 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 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

At issue is Fluticasone-Salmeterol 250-50 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 does 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 Fluticasone-Salmeterol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nucala 100-milligram Auto-Injector to treat severe asthma. 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 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

The enrollee requested Isopto Tears 0.5% solution prescribed while in the hospital. 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, over-the-counter drugs are excluded from coverage under Part D. We determined that the plan is not required to cover the Isopto Tears or provide reimbursement. 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

The enrollee requested Senna Plus 8.6/50/milligram tablet prescribed while in the hospital. 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, over-the-counter drugs are excluded from coverage under Part D. We determined that the plan is not required to cover the Senna Plus or provide reimbursement. 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 formulary exception request for Xeljanz XR 11 milligram tablets prescribed for psoriatic arthritis. 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 prescriber submitted medical records and a supporting statement. The supporting statement did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Xeljanz XR.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vardenafil 10 milligram tablets prescribed for erectile dysfunction. The Part D plan denied the request. We performed and 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 Vardenafil because it was used to treat sexual or erectile dysfunction. Drugs prescribed for the treatment of sexual or erectile dysfunction 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

The enrollee requested First-Lansoprazole 3 milligram/milliliter suspension 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.We determined that the plan is not required to cover the First-Lansoprazole. According to Medicare rules, drugs that fall into the category of bulk powders do not meet the definition of a Part D drug. The First-Lansoprazole is considered a bulk powder and therefore, is excluded from coverage under Part D. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Victoza 2-pack 18 milligrams per 3 milliliters subcutaneous pen-injector. The Part D plan denied the appeal request for a tiering exception.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.Victoza 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 a request for coverage of Lidocaine-Prilocaine 2.5-2.5% topical cream, 90 grams per 30 days. The Part D plan denied the request because the drug was not available for coverage under Medicare Part D. Additionally, the amount of the Lidocaine-Prilocaine cream requested exceeded the plans quantity limit for that drug.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 the Lidocaine-Prilocaine cream is being used as topical anesthesia for dialysis-related services. Drugs used for enrollees receiving dialysis would be covered under Medicare Part B, as these drugs are included in the Medicare Part B bundled payment to an end stage renal disease dialysis facility. Drugs covered under Medicare Part B are not available for coverage under Medicare Part D. Since the drug is not available for coverage, the quantity limit is not applicable to this review.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 requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of a Flovent HFA 110 microgram per actuation aerosol inhaler.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. During this review a prescriber statement of medical necessity and supporting medical records were requested from the prescriber. The prescriber responded and submitted the requested documentation.The newly submitted medical records indicate that the Flovent inhaler is being prescribed for the treatment of asthma, which is a medically accepted indication for the use of Flovent, as outlined in the Medicare approved compendia. The plans quantity limit for the drug is 1 inhaler/canister per 30 days, which is what has been requested. The plan does not have any additional prior authorization requirements for the coverage of this medication. Therefore, the medical records validate that the medication is being prescribed for a medically accepted indication and that the plans quantity limit requirements have not been exceeded. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Dupixent 200 milligram per 1.14 milliliter prefilled subcutaneous injection syringe. The Part D plan denied the request for coverage 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 documentation indicates that Dupixent has been prescribed for the treatment of bullous pemphigoid. The FDA has given Dupixent an orphan drug designation for the treatment of bullous pemphigoid. Therefore, the drug is being prescribed for a medically accepted indication. However, Dupixent is not included in the plans formulary (list of covered drugs). An alternative drug included in the formulary to treat bullous pemphigoid is Methotrexate. The prescriber has noted that Methotrexate is contraindicated in malignancy. It is noted that the enrollee does have a solid organ malignancy. However, Methotrexate is only contraindicated in hematologic malignancies. Therefore, a formulary exception is not supported. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxycontin 80-milligram Tablet Extended Release 12-Hour Abuse-Deterrent to treat chronic back pain and cervicalgia. 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 documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan, with supporting medical documentation, would likely cause harm or not be as effective as the requested drug. 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 Levalbuterol tartrate HFA 45-microgram Inhaler to treat cough related to allergy or cold. 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. No medical records were provided.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

At issue is Multaq 400 milligram tablets. The Part D plan denied the appeal request for a tiering exception.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.Multaq 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 Promethazine Hydrochloride 25 milligram tablets prescribed for nausea and irritable bowel syndrome. 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 Promethazine Hydrochloride for nausea and irritable bowel syndrome. 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: Favorable

At issue is a prior authorization request for Fentanyl 25 microgram/hour patch prescribed for chronic pain severe enough to require daily, around-the-clock long-term treatment. 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. We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the enrollee meets the plans prior authorization coverage criteria. We received the documentation and included it in this review.The enrollee satisfies the plan's coverage criteria. The prescriber submitted a statement and medical records to support the enrollee was prescribed Fentanyl patches for chronic pain severe enough to require daily, around-the-clock long-term treatment. The prescriber attested that the enrollee can safely take the requested dose, will be evaluated and monitored for the development of opioid use disorder, and is a request for continuation of therapy for an enrollee who has been receiving an extended release opioid agent for at least 30 days.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 Modafinil 200 milligram tablet prescribed for major depressive disorder, recurrent, full remission. 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 documentation shows Modafinil was prescribed to treat major depressive disorder, recurrent, full remission. However, 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 Modafinil.