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

At issue is a request for coverage of Cosentyx 150 milligram per milliliter subcutaneous injection pen, 2 pens (300 milligrams) once weekly for 5 weeks, prescribed for inadequately-controlled plaque psoriasis covering 50% of the total body surface area (severe plaque psoriasis). The Part D plan denied the request for coverage because the prior authorization requirements were not met.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 prior authorization requirements for coverage of Cosentyx include the following: the enrollee must have tried and failed or have a contraindication to a non-biologic immunomodulator; the prescriber must be a specialist or has consulted with a specialist for the condition being treated; and the enrollee must not be using Cosentyx concurrently with other biologic drugs (e.g., Humira). Progress notes from a physicians office visit dated June 21, 2021, which were originally submitted to the plan, confirm that the enrollee will not be taking the Cosentyx concurrently with other biologic drugs and that the prescriber is a dermatologist. Progress notes from a physicians office visit dated April 5, 2021, which have been submitted at reconsideration, note that the enrollee has had an adverse reaction to Methotrexate (a non-biologic immunomodulatory) along with kidney issues in the past.The documentation provided 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 Albuterol Sulfate 2.5 milligram/3 milliliter solution prescribed for asthma. The Part D plan denied your 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 Albuterol sulfate 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 Albuterol Sulfate. 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 a tiering exception request for Linzess 145 microgram capsules prescribed for constipation. 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. Linzess is a brand drug on Tier 4 of the plans formulary. During this review, a prescriber statement and supporting medical records were requested from the prescriber to address the tiering exception request. The prescriber did not respond. 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 the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil 50 milligrams denied for an 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. 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 is needed. We did not receive the documentation requested. Without a diagnosis it cannot be established that Sildenafil is being prescribed for a medically accepted indication. As such, Sildenafil 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 Sildenafil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Ongentys 25 milligram capsules prescribed for the management of Parkinsons disease. 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. Ongentys is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all the formulary alternatives that are included in the plan to treat the enrollees condition 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 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 Diclofenac Epolamine 1.3% patch. The redetermination diagnosis given was for acute pain due to trauma/low 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. We asked the prescriber to send us information regarding the enrollee's condition. We also asked for medical records or other documentation to show the medication is needed. We did not receive the documentation requested. At reconsideration a diagnosis of acute pain due to minor sprain was given. Without medical records, it could not be determined whether the requested drug was being prescribed for a medically accepted indication. A physician reviewed your appeal and determined that the plan is not required to Diclofenac Epolamine 1.3% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% ointment prescribed for low 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 Lidocaine was prescribed to treat low back pain. However, the Medicare approved compendia do not support the use of this drug for the enrollee's condition. A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone Cypionate 200-milligrams/milliliter to treat hypogonadism. 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 provided addressed the plans coverage criteria, and those criteria were not satisfied. 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 Lidocaine 5% topical cream prescribed three times daily for low back pain. 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 enrollee needs this medication. We did not receive the documentation requested.The documentation shows the doctor prescribed Lidocaine 5% topical cream to treat the enrollees low back pain. However, the Medicare approved compendia do not support the use of this drug for low back pain. A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine 5% topical cream.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Ubrelvy 50 milligram tablets, 30 tablets per 30 days. The Part D plan denied the tiering request. Additionally, the plan denied the request for 30 tablets per 30 days, as the amount requested exceeded the plans quantity limits.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 already approved coverage of Ubrelvy 50 milligram tablets, 16 tablets per 30 days, which is the quantity limit for this drug that has been set by the plan. The documentation does not support an exception to the quantity limit criteria. Additionally, Ubrelvy is included in Tier 5 of the plans formulary (list of covered drugs). Tier 5 of the plans formulary is the tier reserved for specialty drugs. The specialty tier is exempt from tiered cost-sharing expectations. Therefore, this drug is not eligible for coverage at a lower-cost tier. A physician reviewed the appeal and determined that the plan is not required to cover more than 16 Ubrelvy tablets per 30-day supply. Additionally, the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fondaparinux Sodium 7.5 milligram/0.6 milliliter solution. 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. This drug is included on Tier 5 of the plans formulary. This tier is identified as a Specialty Tier. The plan is not required to grant a tiering exception for drugs available on their Specialty Tier. Therefore, a tiering 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

At issue is Nucynta 50 milligram tablets prescribed 1 tablet at bedtime as needed for chronic pain. The Part D plan denied your request stating the drug is off formulary.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. Nucynya is medically indicated for acute pain. The extended release form is medically indicated for chronic pain. The documents submitted support the drug is being used for chronic pain. Medicare approved compendia do not support the use of this immediate release form of the drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Nucynta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prolia 60 milligram/milliliter prefilled syringe prescribed for osteoporosis. 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 asked the 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 record shows the doctor prescribed Prolia for treatment of osteoporosis with high risk of fracture. The enrollees 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 Prolia. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium 1% Gel. At initial determination and redetermination the diagnosis of disorder of skin and subcutaneous tissue, unspecified was given. 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.At reconsideration a diagnosis of osteoarthritis of the foot was given. No medical records were provided by the prescriber to support this diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. The use of the requested drug to treat the provided diagnosis of disorder of skin and subcutaneous tissue, unspecified 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 Zolpidem Tartrate 5 milligram tablet prescribed every daily. 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 enrollees 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 Zolpidem Tartrate 5 milligram tablet to treat unspecified illness. No medical records were provided by the prescriber to support a covered diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication.A physician reviewed the appeal and determined that the plan is not required to cover Zolpidem Tartrate 5 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Tacrolimus 5 milligram capsules. 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. The medical records indicate that Tacrolimus 5 milligram capsules have been prescribed for the treatment of lichen planopilaris of the scalp. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Ubrelvy 50 milligram tablets prescribed for the treatment of migraines. 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. No medical records were received.The Part D 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Febuxostat 40 milligram tablets prescribed for gout of the right lateral foot. 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. Febuxostat is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives that are included in the plan to treat the enrollees condition 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 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 Cosentyx pen 300 milligram/2 pens (150 milligram/milliliter) 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 records submitted at the reconsideration level. The medical records show Cosentyx was prescribed to treat psoriasis vulgaris. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Cosentyx. 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

The enrollee requested Sodium Chloride 7% Vial. The Part D plan denied the enrollee's 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 Sodium Chloride 7% does not have a National Drug Code directory number that is listed with the Food and Drug Administration. Therefore, we determined that the plan is not required to cover the Sodium Chloride 7% Vial. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil 20 milligram tablet prescribed three times daily for pulmonary hypertension. 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. The documentation shows that the doctor prescribed Sildenafil treat the enrollees pulmonary hypertension. 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 Sildenafil.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested reimbursement for the Adacel TDAP 2-2.5-5/0.2 vaccine prescribed for vaccination. The Part D plan denied the enrollees request.We requested 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.Medicare rules state that drug claims must include a valid National Drug Code that is listed with the Food and Drug Administration. The record includes information indicating the National Drug Code for the vaccine is 49281-0400-88. However, this code is not listed with the Food and Drug Administration as a valid code for Adacel TDAP. Therefore, we determined that the plan is not required to provide reimbursement for the vaccine and administration fee.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Timoptic 0.5% ocudose drops prescribed for primary open angle glaucoma. 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 the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. 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, no medical records have 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 Timoptic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Horizant 600 milligram extended release tablet prescribed for fibromyalgia. 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 physician indicates Horizant is requested due to symptoms of several chronic diseases, including overlap of restless leg syndrome/ peripheral neuropathy, fibromyalgia along with rheumatoid arthritis. However, the medical records submitted support that Horizant 600 milligram extended release tablets are prescribed for the treatment of fibromyalgia. 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 Horizant.