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

At issue is a request for coverage of Lidocaine 5% patches prescribed for radiating back pain. The Part D plan denied the request for coverage stating that the medication was being used for a non-medically accepted indication. 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.During this review, a prescriber statement and supporting medical records were requested from the prescriber to clarify the nature and etiology of the enrollees back pain. The prescriber responded with the requested documentation. The documentation supports that the enrollee has lower back pain that radiates down the right hip and leg, which has an unknown etiology and started about two weeks ago. Therefore, the documentation supports that the Lidocaine patches are being prescribed for radiating back pain that is not of a chronic nature. 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 your appeal and determined that the plan is not required to cover the Lidocaine 5% patches.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a non-formulary exception for Sucralfate 1 gram/10 milliliter suspension prescribed for dyspepsia. 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. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates your doctor prescribed Sucralfate for dyspepsia. The submitted documentation does not contain medical records to support a covered condition. The Medicare approved compendia do not support the use of the drug at issue for your conditions. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch to treat spinal stenosis of the cervical 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.The documentation shows your doctor prescribed Lidocaine 5% patch to treat spinal stenosis of the cervical region. 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

At issue is a formulary exception request for Vumerity 231 milligram DR capsules prescribed for multiple sclerosis. 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. This includes the case file from the plan and any information submitted at the reconsideration level. Your physician submitted a supporting statement. The supporting statement did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Vumerity DR.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Buprenorphine Hydrochloride 8 milligram sublingual tablets prescribed as directed for chronic 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. At redetermination, a diagnosis of chronic pain syndrome and intervertebral disc degeneration of the lumbosacral region was given. At reconsideration, the prescriber states the enrollee is being treated for opioid dependence. The medical records submitted for review do not show that Buprenorphine Hydrochloride was prescribed as part of a complete treatment plan for opioid dependence. The medical records show the enrollee was prescribed Buprenorphine Hydrochloride and Oxycodone for pain control. The Medicare approved compendia do not support the use of the requested drug in the sublingual tablet form for chronic pain. A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine Hydrochloride sublingual tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Xolair 75 milligram/0.5 milliliter syringe prescribed for mild persistent asthma, uncomplicated. The Part D plan denied coverage.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. The documentation on hand includes a physician supporting statement. The supporting statement does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.A physician reviewed your appeal and determined that the requested biologic is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch prescribed for fibromyalgia and hip pain. 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. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates your doctor originally prescribed Lidocaine patches for fibromyalgia and hip pain. Your doctor submitted a statement to indicate the diagnoses billed should include spinal stenosis and multiple sclerosis. The Medicare approved compendia do not support the use of the drug at issue for your conditions. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prednisone 5 milligram tablets prescribed daily following a kidney transplant. 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 information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. Your records show your doctor prescribed Prednisone to prevent rejection following a kidney transplant. The Medicare approved compendia support the use of this drug for your condition. Based on the information provided, the drug is eligible for Part B coverage. Therefore, the drug is not eligible for Part D coverage in this case.   A physician reviewed your appeal and determined that the plan is not required to cover Prednisone.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a quantity limit exception for Fluticasone Propionate 50 microgram spray. 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. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation indicates your doctor prescribed Fluticasone Propionate for allergic rhinitis. Your doctor originally requested two puffs each nostril three times daily or 16 grams for a 15-day supply. Your plan allows 16 grams for a 30-day supply. Your doctor submitted a statement that two puffs in each nostril daily, or 16 grams per 30 days, is sufficient. Therefore, a quantity limit exception cannot be granted and the amount approved by the plan is upheld.Therefore, the plan is not required to cover Fluticasone Propionate for a quantity limit exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a quantity limit exception for Tadalafil 5 milligram tablets prescribed for benign prostatic hyperplasia. 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. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation indicates your doctor prescribed Tadalafil for benign prostatic hyperplasia. Your doctor originally requested 180 tablets for a 90-day supply. Your plan allows 30 tablets for a 30-day supply. Your doctor submitted a statement to indicate the enrollee requires the higher dosage. However, the dosage requested by your doctor is not Food and Drug Administration approved. Therefore, a quantity limit exception cannot be granted and the amount approved by the plan is upheld.Therefore, the plan is not required to cover Tadalafil for a quantity limit exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gammagard Liquid 10% 33 gram intravenous solution prescribed for autoimmune autonomic ganglionopathy and orthostatic hypotension. 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. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates your doctor prescribed Gammagard Liquid 10% intravenous solution for autoimmune autonomic ganglionopathy and orthostatic hypotension. The Medicare approved compendia do not support the use of the biologic at issue for your conditions. As it cannot be determined that the biologic was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tobramycin 0.3% eye drops to treat the enrollees condition.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.This drug is included on Tier 1 of the plans formulary. There are no cost-sharing tiers lower than Tier 1; therefore, a tier exception cannot be considered.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 Mektovi 15 milligram tablets prescribed to treat metastatic pancreatic cancer. 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 the doctor prescribed Mektovi to treat metastatic pancreatic cancer. The enrollee has been treated with Gemcitabine and Abraxane. Molecular profiling showed BRAF mutation so the new treatment plan includes Mektovi, given in combination with Braftovi. The prescriber submitted medical literature for review. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Mektovi.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jardiance 25 milligram tablets prescribed for type 2 diabetes mellitus with hyperglycemia. 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. Jardiance 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 Roxicodone 30 milligram tablets to treat right-sided sciatica and primary osteoarthritis of both knees. 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 Roxicodone 30 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rhofade 1% Cream prescribed for treatment of rosacea. 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, medical records have not been submitted to 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 Rhofade 1% Cream.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Prodigy Voice Glucose Test Strips prescribed for monitoring your blood glucose levels. 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 information submitted at the reconsideration level. Your medical record shows that you are a person with diabetes. Glucose monitoring supplies (test strips) are not considered medical supplies directly associated with the delivery of insulin for purposes of coverage under Medicare Part D. As such, the Prodigy Voice Glucose Test Strips are excluded from Part D coverage by Medicare law.We have determined that your plan is not required to cover Prodigy Voice Glucose Test Strips. Medicare Part B/Durable Medical Equipment is responsible.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage and a tiering exception request for Vancomycin Hydrochloride 125 milligram capsules. The Part D plan denied coverage for the medication and the tiering exception request because the medication was being prescribed for a non-medically accepted indication. 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 Vancomycin Hydrochloride has been prescribed for chronic antibiotic-dependent pouchitis. However, the Medicare approved compendia do not contain any citations to support the use of the requested medication, 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 your appeal and determined that the plan is not required to cover the Vancomycin Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Benzonatate 100-milligram capsule to treat cough due to cold. The Part D plan denied the request. The case was auto-forwarded by the plan.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.Drugs prescribed for the symptomatic treatment of cough and colds are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.A physician reviewed the appeal and determined that the requested drug is excluded from Medicare Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 10 milligram tablets to treat insomnia. 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.Your medical records show your doctor prescribed Zolpidem Tartrate 10 milligram tablets to treat insomnia. 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 Zolpidem Tartrate 10 milligram tablets. 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 Tacrolimus 0.1% ointment prescribed for psoriasis vulgaris. 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 prescriber indicated that Tacrolimus 0.1% ointment is prescribed to treat psoriasis vulgaris. 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 Tacrolimus 0.1% ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tacrolimus 1 milligram capsules prescribed as directed following a liver transplant. 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. We also researched Medicare systems and reviewed the enrollment data available. The record shows the physician prescribed Tacrolimus for immunosuppression following a liver transplant on May 22, 2020. Medicare enrollment records show the enrollee was entitled to the Medicare Part A benefit as of March 1, 2020. This drug may be eligible for coverage under Medicare Part B. Drugs prescribed for immunosuppression following a Medicare covered transplant are eligible for coverage under Medicare Part B. Therefore, this drug is not eligible for coverage under Medicare Part D.We determined that the plan is not required to cover Tacrolimus.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for a tiering exception for Janumet XR 50-1000 milligram 24-hour extended release tablets prescribed for type 2 diabetes mellitus. 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.Janumet XR is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to cover the Janumet XR at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Armodafinil 250 milligram tablets prescribed daily for fatigue related 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. The documentation shows the doctor prescribed Armodafinil to treat fatigue related to multiple sclerosis. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to Armodafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Methylphenidate Hydrochloride ER 20 milligram extended release tablets. The Part D plan denied the request because the prior authorization requirements were not met, as the medication was prescribed for a non-covered diagnosis. 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 Methylphenidate Hydrochloride ER has been prescribed for multiple sclerosis-related fatigue. 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 your appeal and determined that the plan is not required to cover the Methylphenidate Hydrochloride ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Estradiol 0.01% cream to treat vaginal atrophy and pelvic floor muscle weakness. 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.Estradiol 0.01% cream is a generic drug on Tier 3 of the plans formulary. There are no generic drugs of the same type on the lower cost sharing tiers. A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.