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

At issue is Diclofenac Sodium 1 percent gel prescribed as directed for pain in left 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Diclofenac Sodium 1 percent gel to treat your pain in left knee. 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 cover Diclofenac Sodium 1 percent gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine Hydrochloride 10 milligram tablets prescribed to treat an enrollee with rheumatoid arthritis of multiple sites. 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 Cyclobenzaprine Hydrochloride 10 milligram tablets to treat rheumatoid arthritis of multiple sites and muscle spasms related to rheumatoid arthritis and osteoarthritis. 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 chronic conditions. 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 Cyclobenzaprine Hydrochloride 10 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Otezla 30 milligram tablets prescribed for an enrollee with lichen planus affecting hands, arms, feet, and inside of mouth. 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 Otezla 30 milligram tablets to treat lichen planus affecting hands, arms, feet, and inside of mouth. 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. This decision does not speak to the medical necessity of this drug for your condition. This decision speaks to whether your plan is required to provide coverage under Medicare rules.A physician reviewed the appeal and determined that the plan is not required to cover Otezla 30 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Cialis 5 milligram tablet, 30 tablets per 30 days, prescribed for Raynauds 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. The documentation shows Cialis 5 milligram tablet was prescribed for Raynauds syndrome. However, the Medicare approved compendia do not support the use of Cialis 5 milligram per day for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Cialis.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha 140 milligram/milliliter Sureclick prescribed for hyperlipidemia in an enrollee with coronary artery disease. 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. Repatha is a biological product drug on Tier 2 of the plans formulary. There are no biological product 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 Sildenafil 20-milligram tablet to treat pulmonary hypertension, unspecified. This was the diagnosis provided by the prescriber on the Prior Authorization request form dated 8/6/2021.  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. With the reconsideration appeal the prescriber provided an echocardiogram report.  The report lists the diagnoses as congestive heart failure unspecified and pulmonary hypertension, unspecified (I27.20).  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 Serevent Diskus 50 microgram aerosol powder prescribed as directed. 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. Serevent Diskus 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 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 Tramadol ER 100 mg  tablet prescribed for chronic pain.   The Part D plan denied the request.  The requested drug is not on the plans formulary. 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.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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Anecream5 5% cream prescribed for external hemorrhoids. The Part D plan denied your 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 Anecream because it is a non-prescription/over the counter drug. Nonprescription or over-the-counter drugs are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Phospha 250 Neutral 155-852-130 milligram tablets to treat an enrollee with low serum phosphorus level. The Part D plan denied the appeal request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows the physician prescribed Phospha 250 Neutral 155-852-130 milligram tablets. However, the requested drug has not been approved by the United States Food and Drug Administration. Non-Food and Drug Administration approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Privigen 10% 10 grams intravenous solution to treat an enrollee with inflammatory arthritis. The Part D plan denied the appeal request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows the physician prescribed Privigen 10% 10 grams intravenous solution. However, the requested drug has not been approved by the United States Food and Drug Administration. Non-Food and Drug Administration approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vytorin 10/20 milligram tablets prescribed as directed. 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. Vytorin 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 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 Saphris 10 milligram sublingual tablet prescribed for major depressive disorder, recurrent, in partial remission. 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 indicate Saphris 10 milligram sublingual tablet is prescribed for major depressive disorder, recurrent, in partial remission. 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 Saphris.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prolia 60 milligrams per milliliter prescribed every six months for post menopausal osteoporosis. 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 Prolia to treat the enrollees post menopausal osteoporosis. 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 Prolia. 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 a request for coverage of Deferasirox 360 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 medical records indicate that Deferasirox has been prescribed for the treatment of hereditary hemochromatosis. 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 reimbursement for Gemcitabine Hydrochloride 1 gram vial. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted.The drug at issue was dispensed at a pharmacy not in your plans network on the date the prescription was filled. In these instances, you may be responsible for paying the difference between what you pay for the drug at the out of network pharmacy and the cost that we would cover at an in network pharmacy. We determined that the plan is not required to reimburse you for Gemcitabine Hydrochloride 1 gram vial.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armour Thyroid 90 milligram tablets prescribed for hypothyroidism. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The drug at issue is not Food and Drug Administration approved. 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: Favorable

At issue is Tasigna 150 milligram capsule prescribed for Philadelphia chromosome positive chronic myelogenous leukemia. 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.The plan requires for coverage of Tasigna that the enrollee have chronic phase myelogenous leukemia that is resistant or intolerant to prior therapy. The documentation includes clinical notes which satisfythe plan's coverage criteria. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested compounded drug ingredient Estriol 100% powder prescribed for unknown diagnosis. The plan denied the enrollees 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, drugs that fall into the category of bulk powders are excluded from coverage under Part D. The Estriol  100% powder does not meet the definition of a Part D drug. We reviewed Food and Drug Administration (FDA)-approved sources for the drugs classification or determined from other available resources that the drug not an approved drug. Therefore, the compounded drug ingredient Estriol 100% powder is not eligible for Part D coverage. We determined that the plan is not required to cover the Estriol 100% powder. 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

The enrollee requested compounded drug FD&C Yellow #5 powder prescribed for unknown diagnosis. The plan denied the enrollees 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, drugs that fall into the category of bulk powders are excluded from coverage under Part D. The FD&C Yellow #5 powder does not meet the definition of a Part D drug. In addition, Medicare Part D does not cover non-prescription drugs. We reviewed Food and Drug Administration (FDA)-approved sources for the drugs classification or determined from other available resources that the drugs are non-prescription or over-the-counter (OTC) drugs. Therefore, the ingredient FD&C Yellow #5 powder is not eligible for Part D coverage. Therefore, we determined that the plan is not required to cover the FD&C Yellow #5 powder. 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

The enrollee requested compounded drug HRT cream base prescribed for unknown diagnosis. The plan denied the enrollees 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, drugs that fall into the category of bulk powders are excluded from coverage under Part D. The HRT cream base does not meet the definition of a Part D drug. In addition, Medicare Part D does not cover non-prescription drugs. We reviewed Food and Drug Administration (FDA)-approved sources for the drugs classification or determined from other available resources that the drugs are non-prescription or over-the-counter (OTC) drugs. Therefore, the ingredient HRT cream base is not eligible for Part D coverage. Therefore, we determined that the plan is not required to cover the HRT cream base. 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

The enrollee requested compounded drug Hypromellose powder prescribed for unknown diagnosis. The plan denied the enrollees 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, drugs that fall into the category of bulk powders are excluded from coverage under Part D. The Hypromellose powder does not meet the definition of a Part D drug. In addition, Medicare Part D does not cover non-prescription drugs. We reviewed Food and Drug Administration (FDA)-approved sources for the drugs classification or determined from other available resources that the drugs are non-prescription or over-the-counter (OTC) drugs. Therefore, the ingredient Hypromellose powder is not eligible for Part D coverage. Therefore, we determined that the plan is not required to cover the Hypromellose powder. 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

The enrollee requested compounded drug ingredient Progesterone Micronized 100% powder prescribed for unknown diagnosis. The plan denied the enrollees 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, drugs that fall into the category of bulk powders are excluded from coverage under Part D. The Progesterone Micronized 100% powder does not meet the definition of a Part D drug. We reviewed Food and Drug Administration (FDA)-approved sources for the drugs classification or determined from other available resources that the drug not an approved drug. Therefore, the compounded drug ingredient Progesterone Micronized 100% powder is not eligible for Part D coverage. We determined that the plan is not required to cover the Progesterone Micronized 100% powder. 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 Erbitux 200 milligram/100 milliliter intravenous solution prescribed for pancreatic cancer. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates the drug at issue is to be administered intravenously via an implanted port. The drug is eligible for coverage under Part B. The drug is not eligible for coverage under Part D. The plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Super B Complex Maxi tablet prescribed 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, drugs that fall into the category of vitamins and minerals are excluded from coverage under Part D. The requested drug is available without a prescription and is available over-the-counter. Therefore, we determined that the plan is not required to cover the Super B Complex Maxi. The plan does not indicate that supplemental coverage is provided for the Super B Complex Maxi. 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.