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

At issue is Trintellix 10 milligram tablet prescribed daily for major depression disorder. 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. Trintellix 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 coverage for Amitiza 24 microgram capsules prescribed for chronic idiopathic constipation. 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.Amitiza 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 would likely not be as effective as the requested drug for the noted condition and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Retacrit 20000-units/milliliter to treat anemia in stage 4 chronic kidney disease. 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 satisfies the plans 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

At issue is coverage for Testosterone 1.62% gel pump prescribed for testicular 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 criteria. The prescriber has not sufficiently addressed the plans criteria for continued coverage of Testosterone and/or the continued 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

At issue is Zenpep DR 25-79-105K capsules prescribed for exocrine pancreatic insufficiency. 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. Zenpep DR is a biological product drug on Tier 3 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 a request for coverage of Xadago 50 milligram tablets, 180 tablets per 90 days, prescribed for Parkinsons disease. The Part D plan approved a non-formulary exception for the Xadago but denied the request for a 90-day supply of the medication.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 has approved coverage for the Xadago, which is not included on the plans formulary. The prescriber has requested a 90-day supply of the drug; however, the plan limits non-formulary drugs to a recurring 30-day supply. An exception to the quantity limit criteria has not been met. A physician reviewed the appeal and determined that the plan is not required to cover a 90-day supply of Xadago.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Leflunomide 20 milligram tablets to treat rheumatoid arthritis. 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.Leflunomide is a generic drug on Tier 3 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 Acetylcysteine 20% Solution to treat filamentary keratitis. 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 also researched Medicare systems and reviewed the enrollment data available.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 Nourianz 20 milligram tablets prescribed for Parkinsons disease. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.We asked 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 some of the documentation requested.Documentation shows your doctor prescribed Nourianz to treat your Parkinsons disease. 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 Nourianz. 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 Xeljanz XR 11 milligram tablets to treat rheumatoid arthritis. 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 Xeljanz XR 11 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Propylene glycol prescribed for hormone replacement therapy. 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. The record shows the Propylene glycol is an ingredient within a compounded drug. Some of the ingredients within the compounded drug are non-prescription drugs and are not eligible for Part D coverage. According to the Food and Drug Administration, the National Drug Code provided for the Propylene glycol is not a valid code. Therefore, we determined that the plan is not required to reimburse you for the Propylene glycol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Testosterone powder prescribed for hormone replacement. 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 record shows the Testosterone powder is an active ingredient within a compounded drug and is reviewed individually. Medicare Part D does not cover non-prescription drugs. Some of the ingredients within the compounded drug are non-prescription drugs and are not eligible for Part D coverage. We also found that the National Drug Code submitted for this active ingredient is not listed with the Food and Drug Administration as a valid code. Therefore, we determined the plan is not required to cover the Testosterone powder.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Versabase cream prescribed for hormone replacement. 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 record shows the Versabase cream is a compounded drug and each ingredient is reviewed individually. Medicare Part D does not cover non-prescription drugs. Some of the ingredients within the compounded drug are non-prescription drugs and are not eligible for Part D coverage. We also found that the National Drug Code submitted for this active ingredient is not listed with the Food and Drug Administration as a valid code. Therefore, we determined the plan is not required to cover the Versabase cream.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Lidocaine 5% ointment, 250 grams per 30 days. The Part D plan denied the request for coverage because the medication was being prescribed for a non-medically accepted indication. Additionally, the amount of medication requested exceeded the plans quantity limits.   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 initially submitted to the plan indicates that Lidocaine ointment has been prescribed for complex regional pain syndrome of right lower limb. However, the Medicare approved compendia do not contain any citations to support the use of Lidocaine ointment for the treatment of complex regional pain syndrome of right lower limb.At reconsideration, the prescriber has noted that the Lidocaine ointment is also being used for anesthesia of the skin. As noted in the Medicare approved compendia, Lidocaine 5% topical ointment is indicated for use as a local anesthetic to the skin for the temporary relief of pain associated with minor burns, including sunburn, abrasions of the skin, and insect bites. However, the prescriber has not specified why the enrollee needs anesthesia of the skin. Furthermore, no supporting medical records have been submitted to validate the additional diagnosis. Therefore, there is insufficient documentation to determine if the Lidocaine 5% ointment is being prescribed for a medically accepted indication and the drug is not eligible for coverage under Medicare Part D. Since the drug is not eligible for coverage under Medicare Part D, the plans quantity limits criteria are not applicable to this review. A physician reviewed the appeal and determined that the plan is not required to cover the Lidocaine 5% ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aimovig 140-milligrams/milliliter to treat chronic migraines. 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

At issue is Nexium Delay Release 40-milligram Tablet to treat dysphagia. 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 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 prescribed Austedo 6 milligram oral tablet. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.We asked 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.Your medical records show your doctor prescribed Austedo to treat your drug induced subacute dyskinesia or tardive dyskinesia. 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 Austedo. 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 Lidocaine 5% Patch. At initial determination and redetermination the diagnoses of lower back pain and sprained ligaments of the lumbar spine were given. 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.At reconsideration diagnoses of arthropathic psoriasis and lumbago were given. The use of the requested drug to treat the provided diagnoses are off-label uses. 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: Favorable

At issue is Epidiolex 100 milligram/milliliter oral solution prescribed for adjunctive treatment for localization-related symptomatic epilepsy with simple partial seizures, intractable, without status epilepticus.   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 following citation in DrugDex, a Medicare approved compendium, supports the use of the requested drug for the enrollees condition: Adjunctive cannabidiol significantly decreased seizure frequency at week 12 and the improvement was stable over 48 weeks in 2 open-label studies of treatment-resistant epilepsy in children and adults. Therefore, the requested drug is being prescribed for a medically accepted indication. The documentation does not satisfy the plans coverage criteria.  The plans coverage criteria requires an FDA approved indication.  Therefore, an exception to the plans coverage criteria is medically necessary. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Xiidra 5 % eye drops in a dropperette to treat dry eye 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.In the Reconsideration appeal the prescriber provided medical records which show that the enrollee did try and fail Restasis in 2013. The documentation satisfies the plans 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

At issue is Belbuca 75 microgram film, prescribed buccally every 12 hours to treat myelopathy or radiculopathy of the lumbosacral region. 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 Belbuca 75 microgram film.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Promethazine Hydrochloride 25 milligram tablets. The Part D plan denied the request 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 submitted medical records indicate that Promethazine Hydrochloride has been prescribed for chronic nausea, malignant neoplasm of unspecified site of unspecified female breast, breast cancer causing chronic nausea, gastroparesis, chemotherapeutics causing chronic nausea, nausea related to antiepileptics. 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 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 your appeal and determined that the plan is not required to cover the Promethazine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pramipexole Dihydrochloride ER 2.25 milligram tablets to treat Parkinsons disease. 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 Pramipexole Dihydrochloride ER 2.25 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq ER 25 milligram tablets prescribed for urge incontinence. 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. Myrbetriq ER is a brand name drug on Tier 4 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

You requested Est Estrogens-methyltest HS .625/1.25/milligram tablets prescribed for hormone replacement. 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 record shows Est Estrogens-methyltest HS is identified as a less than effective Drug Efficacy Study Implementation drug on the Medicare website.We determined that the plan is not required to cover Est Estrogens-methyltest HS. Medicare Part D does not cover less than effective Drug Efficacy Study Implementation drugs. If you purchase drugs that are excluded, you must pay for them out-of-pocket. 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.