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

At issue is Toviaz 4 milligram tablets prescribed to treat an enrollee with overactive bladder. The Part D plan denied the formulary exception 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.Toviaz is not included on the plans formulary (list of covered drugs). In order to grant an exception for a drug not on the plans formulary, all alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all of the formulary alternatives included on the plan would not work for the enrollee.A physician reviewed the appeal and determined that the plan is not required to cover Toviaz 4 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fentanyl Patch 37.5 microgram/hour 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 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. 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. A physician reviewed your appeal and determined that the plan is not required to cover Fentanyl Patch 37.5 microgram/hour.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Suprep Bowel Prep 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. Suprep Bowel Prep Kit is a brand drug on Tier 4 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 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 Mycophenolate Mofetil 500 milligram tablet prescribed twice daily for unspecified toxic liver 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 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 Mycophenolate Mofetil to treat the enrollees unspecified toxic liver disease.  The prescriber sent a letter dated 8/2/2021 clarifying the medical history.  Medical records from date of service 7/26/2021 were provided.  The prescriber states that Mycophenolate Mofetil is being used to treat hepatotoxicity likely due to a checkpoint inhibitor.  The enrollee has used Pembrolizumab in the past for malignant mesothelioma.  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 plan is not required to cover Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium Gel 1% prescribed for arthritis of the hand and knees. The Part D plan denied the request stating the drug is not medically indicated for this condition.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 prescriber has asked for Diclofenac Sodium Gel 3% but this review is limited to what the redetermination review was for, which is Diclofenac Sodium 1% gel. A new request to the plan will need to be asked for the 3% strength of Diclofenac Sodium Gel. Diclofenac Sodium Gel 1% is prescribed for arthritis of the hand and knees which is a medically accepted indication for use of this drug. However, Diclofenac Sodium Gel 1% is available over-the-counter. Non-prescription drugs are excluded from Medicare Part D drug benefits. A physician reviewed your appeal and determined that the plan is not required to cover Diclofenac Sodium Gel 1%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Linzess 72-microgram capsule to treat constipation. 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.Linzess is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Zolpidem Tartrate 5 milligram tablets. The Part D plan denied the request for coverage because the plans prior authorization requirements were not met.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 medical records indicate that Zolpidem Tartrate has been prescribed for bipolar disorder. However, the Medicare approved compendia do not contain any citations to support the use of 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. Since the drug is not eligible for coverage, the plans prior authorization requirements are not relevant to this review. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vraylar 1.5 milligram capsules prescribed as directed for bipolar II disorder. 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 documentation shows your doctor prescribed Vraylar to treat your bipolar II disorder. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Vraylar.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested prior authorization for Budesonide EC 3 milligram capsule prescribed as directed for irritable bowel syndrome without diarrhea. 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 documentation shows your doctor prescribed Budesonide EC to treat your irritable bowel syndrome without diarrhea. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Budesonide EC.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fenoprofen Calcium 600 milligram tablets prescribed as directed for bilateral primary osteoarthritis of knee. 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. 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 your appeal and determined that the plan is not required to cover Fenoprofen Calcium.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Megestrol Acetate 40 milligram tablets. 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 Megestrol Acetate has been prescribed for weight loss and failure to thrive due to the presence of Alzheimers disease. 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 the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Promacta 50 milligram tablet prescribed daily for immune thrombocytopenia purpura in an enrollee with myelopdysplastic 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 the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any records submitted at the reconsideration level.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication was needed. We received the documentation and included it in our review.The doctor prescribed Promacta to treat the enrollees immune thrombocytopenia purpura and the prescriber stated that the enrollee has myelopdysplastic syndrome.  The label, available at Drugs@FDA.gov states:  'Limitations of Use:  PROMACTA is not indicated for the treatment of patients with myelodysplastic syndrome (MDS).'  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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gammaked Solution 5 gram/50 milliliter prescribed for idiopathic autonomic neuropathy and small fiber neuropathy. 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 the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The documentation submitted from the prescriber indicates Gammaked Solution is prescribed for idiopathic autonomic neuropathy and small fiber neuropathy. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Gammaked Solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 10 milligram tablet prescribed daily for 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.The doctor prescribed Zolpidem Tartrate to treat the enrollees 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 your 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. A tiering exception could not be assessed because the prior authorization requirements were not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xarelto 20 milligram tablets. 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,Xarelto is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no brand 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

You requested Megestrol Acetate suspension 625 milligram/5 milliliter prescribed as directed for anorexia. 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 documentation shows your doctor prescribed Megestrol Acetate to treat your anorexia. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Megestrol Acetate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Onetouch Verio test strips prescribed as directed. 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 you requested coverage for Onetouch Verio test strips. However, this product may be eligible for coverage under Medicare Part B. Medicare rules state drugs and medical supplies not directly associated with the injection of insulin are not 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.We determined that the plan is not required to cover Onetouch Verio test strips.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ozempic 0.25 or 0.5 milligrams subcutaneous pen injector to treat an enrollee with metabolic syndrome. 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 Ozempic 0.25 or 0.5 milligrams subcutaneous pen injector to treat metabolic syndrome. 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 Ozempic 0.25 or 0.5 milligrams subcutaneous pen injector.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nurtec 75-milligram tablet to treat chronic migraine without aura, intractable without status migrainosus. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.We asked your prescriber to send us a prescriber statement, answers to prior authorization coverage criteria, and medical records. However, we did not receive the documentation.Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Tadalafil 2.5 milligram tablets prescribed for an unknown condition. 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. The available documentation does not include the enrollees diagnosis. During this review, a request was submitted to the prescriber to provide the enrollees diagnosis, to address the plans prior authorization requirements for coverage of this this drug, and to submit supporting medical records. The prescriber did not respond to the request. Without a diagnosis, it is not possible to determine if the requested drug is being prescribed for a medically accepted indication outlined in the Medicare approved compendia. As such, the 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 a request for coverage of Acthar Gel 80 unit per milliliter vial for injection prescribed for the treatment of nephrotic syndrome. 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. Acthar Gel 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, the plan's formulary exception criteria have not been met. 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 Sildenafil Citrate 20 milligram tablet prescribed daily. 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 this medication was needed. We did not receive the documentation requested.The doctor prescribed Sildenafil Citrate. There was no diagnosis or medical records provided by the prescriber to support a covered condition. It could not be determined whether the requested drug was being prescribed for a medically accepted indication.A physician reviewed the appeal and determined that the plan is not required to cover Sildenafil Citrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a non-formulary exception request for Incruse Ellipta 62.5 microgram inhalation powder. 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. The available documentation indicates that Incruse Ellipta has been prescribed for the treatment of asthma. However, the Medicare approved compendia do not contain any citations to support the use of Incruse Ellipta for the treatment of asthma.During this review, several attempts were made to contact the prescriber to determine if the enrollee also has chronic obstructive pulmonary disease, which is a medically accepted indication for the use of Incruse Ellipta. However, the prescriber was unable to be reached by fax or phone. Therefore, the available documentation does not support that the requested drug is being prescribed for a medically accepted indication. As such, the 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 reimbursement for One Touch Ultra 2 Kit. 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. Test strips, lancets, and needle disposal systems are not considered medical supplies directly associated with the delivery of insulin for purposes of coverage under Part D. However, this item may be eligible for coverage under Medicare Part B. We determined that the plan is not required to cover reimbursement of One Touch Ultra 2 Kit.