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

At issue is Clomiphene Citrate 50-milligram tablet to treat male hypogonadism.   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

You requested Azathioprine 50 milligram tablet prescribed daily for post-kidney transplant rejection prophylaxis. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. We also researched Medicare systems and reviewed the enrollment data available. The record shows you received a kidney transplant and require the prophylaxis drug. However, this drug may be eligible for coverage under Medicare Part B. Azathioprine is a medication used for transplant rejection prophylaxis.We determined that the plan is not required to cover Azathioprine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tacrolimus 0.5 milligram tablet prescribed 4 tablets twice daily for post-kidney transplant rejection prophylaxis. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. We also researched Medicare systems and reviewed the enrollment data available. The record shows you received a kidney transplant and require the prophylaxis drug. However, this drug may be eligible for coverage under Medicare Part B. Tacrolimus is a medication used for transplant rejection prophylaxis.We determined that the plan is not required to cover Tacrolimus.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone Cypionate 200 milligrams. 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 order to establish medical necessity and confirm that the requested drug is being used for a medically accepted indication, as required by Medicare, medical records supporting that medically accepted indication are required. These records were requested from the prescriber, and we did not receive information that could answer these medical necessity issues.  A physician reviewed your appeal and determined that the plan is not required to cover Testosterone Cypionate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methocarbamol 750 milligram tablet prescribed for an unknown diagnosis. The Part D plan did not render a decision on your request in a timely fashion.  The case was forwarded for a decision to be made.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 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 the documentation requested. Without a diagnosis, it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D.  A physician reviewed your appeal and determined that the plan is not required to cover Methocarbamol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Zolpidem Tartrate 5 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. 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 the documentation requested.The documentation includes valid proof of payment for reimbursement. However, there was no diagnosis given and no medical records submitted for review. Therefore, it cannot be determined if the requested drug was prescribed for a medically accepted indication supported by the Medicare approved compendia. As such, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Zolpidem Tartrate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Carbidopa-Levodopa 10-100 milligram tablet prescribed two tablets four times daily for unknown diagnosis. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. A request was submitted to the prescriber to provide a diagnosis, to address the prior authorization criteria, and to provide supporting medical records.  A reply from the prescriber was not received.  Without a diagnosis, it cannot be established that the requested drug is being prescribed for a medically accepted indication.  As such, the requested drug does not satisfy the definition of a Medicare Part D drug.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.  A physician reviewed your appeal and determined that the plan is not required to reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Celecoxib 200 milligram capsules prescribed twice a day for osteoarthritis of right wrist. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. 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 received the documentation and included it in our review.Your medical records show your doctor prescribed Celecoxib to treat your osteoarthritis of the right wrist. Your plan has step therapy 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 Celecoxib. Our physician reviewer's opinion is that neither step therapy nor step therapy exception criteria are met.
Appeal type: Prescription Drug
Decision: Favorable

You requested reimbursement for $28.34 for Oxycodone 10 milligram tablets purchased on April 21, 2021. 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 submitted documentation includes the required information including proof of payment for the Oxycodone. Therefore, we have determined that the Part D plan is required to reimburse you $28.34 for the Oxycodone tablets for the date of service of April 21, 2021.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hepatitis A vaccine prescribed for no diagnosis provided. 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 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 the documentation requested.The documentation shows you received Hepatitis A vaccine. However, no medical records were provided by the prescriber to support a diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover Hepatitis A vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Glucerna 1.5 calories liquid 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, over-the-counter drugs are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover or reimburse you for Glucerna 1.5 calories liquid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Modafinil 200 milligram tablets prescribed to treat obstructive sleep apnea. 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 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 the requested documentation.Your doctor prescribed Provigil (the brand drug name for Modafinil) 200 milligram tablets. 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 Provigil (Modafinil) 200 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Rena-Vite 0.8-milligram tablets prescribed as directed. 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 Rena-Vite because prescription vitamin and mineral products are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. 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

You requested reimbursement for Estradiol 1 milligram/gram vaginal cream compound 100 percent bulk powder prescribed as directed.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 QIC notes this drug is a compounded drug. Therefore, we reviewed each ingredient individually.Bulk powders (that is, active pharmaceutical ingredients for compounding) do not satisfy the definition of a Part D drug and are not covered by Part D. Therefore, the Estradiol powder ingredient is not eligible for Part D coverage. The plan is not required to provide reimbursement for it. This decision does not address the medical necessity of this drug. It only means that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch prescribed daily as needed for back pain. 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 Lidocaine 5% patch to treat your back pain. 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 Lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Twinrix 720-20 LEU-MCG/ML suspension prefilled syringe for vaccination. 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. The record shows you received the Twinrix vaccination at a clinic. According to your plan's Evidence of Coverage, if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, a reimbursement request form and proof of payment in the form of a receipt showing the amount that you paid for the vaccine was not provided. Therefore, we determined that the plan is not required to reimburse you.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xeljanz 10 milligram tablets prescribed as directed for livedoid vasculitis. 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 Xeljanz to treat your livedoid vasculitis. 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 Xeljanz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested compounded drug Estriol 0.5% cream prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. Estriol cream is a compounded drug and does not have a National Drug Codes verified with the Food and Drug Administration. Therefore, the compounded drug is not eligible for coverage under Medicare Part D. We determined the plan is not required to provide reimbursement for the compounded drug Estriol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xolair Solution 300 milligram every 4 weeks prescribed for recurrent angioedema in the absence of pruritis and urticaria. The Part D plan denied your 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.Your prescriber indicates that Xolair Solution is prescribed for recurrent angioedema in the absence of pruritis and urticaria. Medicare approved compendia does not support this drug for this condition.A physician reviewed your appeal and determined that the plan is not required to cover Xolair Solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Doxycycline Hyclate 50 milligram capsules 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. Doxycycline Hyclate is a generic drug on Tier 3 of the plans formulary. The plan's formulary could not be evaluated for lower tier alternatives, as the use of the requested medication for Lichen planopilaris is not supported by the Medicare approved compendia. 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 Cinacalcet HCL 30 milligram tablet for unknown diagnosis. 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.The record shows you purchased the Cinacalcet HCL at an out-of-network pharmacy. The plans Evidence of Coverage states that drugs you get from an out-of-network pharmacy that do not meet out-of-network plan requirements are not covered by your prescription drug plan. We determined that the plan is not required to reimburse you for the Cinacalcet HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Sucraid 8500 units per milliliter solution. 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 Sucraid has been prescribed for the treatment of secondary (acquired) sucrase-isomaltase deficiency. 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. As noted in the Medicare approved compendium, American Hospital Formulary Service Drug Information, Sucraid has not been evaluated in patients with secondary (acquired) disaccharidase deficiencies. 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 Sucraid.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Topiramate 25 milligram tablets prescribed to treat bipolar disorder and partial seizures. 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 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 the requested documentation.The Part D plan denied your request stating that the provided diagnosis of bipolar disorder is a non-medically accepted indication. Upon reconsideration, the prescribers statement indicates Topiramate 25 milligram tablets is prescribed to treat partial seizures. However, no medical records have been provided to determine if this enrollee has met the criteria for a medically acceptable indication per the approved Medicare compendia.A physician reviewed your appeal and determined that the plan is not required to cover Topiramate 25 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Repatha Sureclick Solution Auto-Injector 140 milligram/milliliter prescribed to treat atherosclerotic heart disease and hyperlipidemia. The Part D plan denied the request. We performed 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. Repatha Sureclick was prescribed to treat atherosclerotic heart disease and hyperlipidemia. The drug is not on the plans formulary. 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 Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Butalbital-Acetaminophen-Caffeine 50-300-40 milligram capsules prescribed to treat rheumatoid arthritis, fibromyalgia, lumbar degenerative disc disease, and lumbar stenosis with neurogenic claudication. 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 Butalbital-Acetaminophen-Caffeine 50-300-40 milligram capsules to treat rheumatoid arthritis, fibromyalgia, lumbar degenerative disc disease, and lumbar stenosis with neurogenic claudication. However, the Medicare approved compendia do not support the use of this drug for your conditions.A physician reviewed your appeal and determined that the plan is not required to cover Butalbital-Acetaminophen-Caffeine 50-300-40 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 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. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch prescribed daily for left foot neuropathic pain due to 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. Your doctor clarified the diagnosis in a letter dated 5/18/2021.  The documentation shows your doctor prescribed the Lidocaine patch to treat your left foot neuropathic pain due to multiple sclerosis. 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 the Lidocaine patch.