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

At issue is Omega-3-Acid Ethyl Esters 1 gram capsules prescribed to treat mixed hyperlipidemia. The Part D plan denied the appeal request.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.The documentation shows the doctor prescribed Omega-3-Acid Ethyl Esters 1 gram capsules to treat mixed hyperlipidemia. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed the appeal and determined that the plan is not required to cover Omega-3-Acid Ethyl Esters 1 gram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tazorac 0.1 % gel prescribed for actinic keratosis. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked the the prescriber to send us information regarding the enrollee's condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. A reply from the prescriber was not received.  The documentation shows Tazorac 0.1 % gel prescribed to treat actinic keratosis. However, the Medicare approved compendia do not support the use of this drug for the enrollee's condition. The following citation in DrugDex, a Medicare approved compendium, does not support the use of the requested drug for the enrollee's condition:  Safety and effectiveness have not been established for prevention or treatment of actinic keratoses, skin neoplasms, or lentigo maligna.A physician reviewed your appeal and determined that the plan is not required to cover Tazorac.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Chlordiazepoxide Hydrochloride 10 milligram capsule prescribed daily for anxiety disorder and 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 information 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 the medication was needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. However, we did not receive the documentation.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 documentation provided does not support why other drugs on the plans formulary would not work. A physician reviewed the appeal and determined that the plan is not required to cover Chlordiazepoxide Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pempro 0.3-1.5 milligram tablet prescribed for menopausal and female climacteric state. 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 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 Pempro.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Belsomra 10 milligram tablet prescribed daily at bedtime for anxiety disorder. The Part D plan did not make a decision.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked the prescriber to send us information regarding the enrolees 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 Belsomra to treat the enrollees anxiety disorder. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Belsomra.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Corlanor 5 milligram tablets prescribed as directed for heart failure due to dilated cardiomyopathy. 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 enrollee has stable, symptomatic chronic heart failure with reduced (<35%) baseline left ventricular ejection fraction. There is documented intolerance to beta-blockers (June 2019), a sinus rhythym greater than 70 has been documented. 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 Nucala 100 milligrams per milliliter solution auto-injector prescribed to treat mild persistent asthma with acute exacerbation. The Part D plan denied the appeal request.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.The documentation shows the doctor prescribed Nucala 100 milligrams per milliliter solution auto-injector to treat mild persistent asthma with acute exacerbation. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed the appeal and determined that the plan is not required to cover Nucala 100 milligrams per milliliter solution auto-injector.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5-milligram tablet prescribed for anticoagulation in an enrollee with Atrial Fibrillation. 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. Eliquis 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

The enrollee requested Clopidogrel 300 milligram tablet prescribed for unknown diagnosis. The Part D 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.The record shows Clopidogrel was given as a self administered drug to the enrollee while inpatient in the hospital. The enrollee provided National Drug Code 2000-0053-17 for the repackaged Clopidogrel. However, this code is not listed with the Food and Drug Administration as a valid code. Therefore, we determined that the plan is not required to cover or provide reimbursement for the Clopidogrel. This decision does not concern 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 Octreotide Acetate 100-micrograms/milliliter. At initial determination and redetermination the diagnosis of adverse effects of unspecified prescription medications biological substances sequela and malignant neoplasm of duodenum. 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. At reconsideration a diagnosis of refractory uncomplicated chemotherapy-induced diarrhea was given. 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 Vimpat 100 milligram tablets prescribed to treat localized related symptomatic epilepsy and epileptic syndromes with complex partial seizures. 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. Vimpat is a brand drug on Tier 4 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.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 asked for reimbursement for Shingrex for Suspension 50 microgram/0.5 milliliter injection. 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 information provided does not include a receipt showing the amount requested of $590.50 was paid for this drug. There is no supporting documentation showing the amount was actually paid.We determined that the plan is not required to cover Shingrex injection.
Appeal type: Prescription Drug
Decision: Favorable

The enrollee requested Shingrix 50/0.5 milliliter injection prescribed for shingles vaccination. We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows the enrollee received the Shingrix vaccine at the enrollees physicians office. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. The plans Evidence of Coverage states that payment for vaccines including administration fee is required up front from the enrollee when provided at an out of network pharmacy or provider's office. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The plans formulary shows the drug is covered as a Tier 3 drug. The documentation submitted includes a statement from the physicians office that shows the Shingrix vaccine and administration fee was paid in full by the enrollee. Therefore, we determined that the plan is required to reimburse you for their share of the cost for the Shingrix vaccine and administration fee for date of service May 19, 2021.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eysuvis 0.25% eye drops prescribed to treat dry eye syndrome. The Part D plan denied the appeal request.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.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 the enrollee.A physician reviewed the appeal and determined that the plan is not required to cover Eysuvis 0.25% eye drops.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aubagio 14-milligram tablet to treat multiple sclerosis. 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 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 NP Thyroid. 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. NP Thyroid has not been found by the Food and Drug Administration (FDA) to be safe and effective, and the drug product labeling had not been approved by the FDA. Drugs not approved by the FDA are excluded from Part D coverage. 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: Unfavorable

At issue is a request for coverage of Doxycycline Hyclate 100 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 submitted to the plan indicates that Doxycycline Hyclate has been prescribed for the treatment of osteoarthritis of the knee. At reconsideration, it is noted that the prescriber has listed the drug for appeal as Doxycycline Monohydrate. However, as noted previously, the drug under appeal is Doxycycline Hyclate. Additionally, the prescriber has stated that the drug is being prescribed for osteoarthritis of the knee as well as spinal stenosis of the lumbar region. However, the Medicare approved compendia do not contain any contain any citations to support the use of Doxycycline Hyclate for the treatment of osteoarthritis of the knee or spinal stenosis of the lumbar region. Therefore, the drug is being prescribed for non-medically accepted indications 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

The enrollee requested Ipratropium-Albuterol 0.5-3 milligram/3 ampule 180 milliliter vial prescribed for the treatment of chronic obstructive pulmonary disease. The Part D plan denied the enrollees request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows the Ipratropium-Albuterol is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover the Ipratropium-Albuterol. Please consider submitting this request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metformin Extended Release Osmotic tablet to treat Type 2 diabetes mellitus with hyperglycemia. The Part D plan forwarded 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.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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Promethazine HCL 25 milligram tablet prescribed for migraine without aura, intractable, without status migrainosus related pain and nausea. The Part D plan denied your request because the diagnosis was not a medically accepted indication for the requested 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 shows Promethazine was prescribed for migraine without aura, intractable, without status migrainosus related pain and nausea. You requested a tiering exception of the plans formulary for Promethazine HCL. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, a tiering exception cannot be considered.A physician reviewed your appeal and determined that the plan is not required to cover Promethazine HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Verzenio 200 milligram tablet to treat metastatic, hormone receptor positive, human epidermal growth factor receptor 2 (HER2) negative breast cancer in combination with Fulvestrant with disease progression following endocrine therapy. The Part D plan did not make a decision.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.Medical records were provided. The enrollees prior therapies included Capecitabine, Everolimus, Exemestane, Letrozole and Palbociclib. The prescriber states the enrollee has experienced disease progression on a cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitor that requires a change in therapy. 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 Nurtec ODT 75 milligram tablet prescribed for hemiplegic migraine. 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 prescribers statement does not support why other drugs on the plans formulary would not work for the enrollee.  Note that with the Reconsideration appeal that medical records were requested.  No medical records were provided.  A physician reviewed your appeal and determined that the plan is not required to cover Nurtec ODT.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Corlanor 5-milligram tablet to treat postural orthostatic tachycardia syndrome, inappropriate sinus tachycardia, and dysautonomia. 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 Corlanor to treat your postural orthostatic tachycardia syndrome, inappropriate sinus tachycardia, and dysautonomia. However, the Medicare approved compendia do not support the use of this drug for your condition. 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 Diltiazem 180 milligram extended-release 24-hour tablets prescribed to treat hypertension.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.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 the enrollee.A physician reviewed the appeal and determined that the plan is not required to cover Diltiazem 180 milligram extended-release 24-hour tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Arikayce 590 milligram per 8.4 milliliter nebulizer solution prescribed for the treatment of Mycobacterium avium complex lung disease caused by Mycobacterium intracellulare infection. 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 plan has prior authorization requirements that must be met before coverage of this medication will be approved. 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.