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

At issue is Lidocaine 5% transdermal patch prescribed twice daily. 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 records 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 neeed. We did not receive the documentation requested.At reconsideration a diagnosis of diabetic neuropathy 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. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the plan is not required to cover Lidocaine 5% transdermal patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Forteo 620 microgram/2.48 milliliter pen injector prescribed daily for osteoporosis without current pathological fracture. 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 records submitted at the reconsideration level. The request states the doctor prescribed Forteo to treat the enrollees osteoporosis without current pathological fracture. 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 the appeal and determined that the plan is not required to cover Forteo. Enrollees who have received a parathyroid hormone analog for more than 24 months in their lifetime do not meet the coverage criteria. 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 Sildenafil 100 milligram tablet prescribed daily as needed for erectile dysfunction. The Part D plan did not make a decision. We performed and 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 determined that the plan is not required to cover Sildenafil because it was used to treat sexual or erectile dysfunction. Drugs prescribed for the treatment of sexual or erectile dysfunction are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, they must pay for them. 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

At issue is a request for coverage of Corlanor 5 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 indicates that Corlanor has been prescribed for the treatment of inappropriate sinus tachycardia. 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 tiering exception request for Bystolic 10 milligram tablets prescribed for the Enrollees condition. 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.Bystolic 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 the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Motegrity 2 milligram tablets prescribed for chronic constipation. 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. Motegrity 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

At issue is a request for coverage of a Tresiba Flextouch U-200 (200 units per milliliter) subcutaneous insulin injection pen prescribed for type 2 diabetes with hyperglycemia. 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. Tresiba Flextouch 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 Xeljanz 11 milligram tablets prescribed daily for rheumatoid arthritis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Xeljanz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Neurontin 400 milligram capsule prescribed every eight hours for idiopathic progressive neuropathy and giant cell arteritis. 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 records submitted at the reconsideration level.The doctor prescribed Neurontin 400 milligram capsule to treat the enrollees idiopathic progressive neuropathy and giant cell arteritis. At reconsideration a diagnosis of postherpatic neuropathy was given. However, the medical records failed to support this 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 the appeal and determined that the plan is not required to cover Neurontin 400 milligram capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Epogen 4000 unit per milliliter vial for subcutaneous injection prescribed for anemia in chronic kidney 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. Epogen 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 alternative 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.It is noted that the prescriber has written Retacrit as the drug they asked the plan to cover on the submitted reconsideration request form. However, this is a reconsideration review for the drug, Epogen, which was denied by the plan. If the prescriber wishes to change the drug from Epogen to Retacrit, which is included in the plans formulary, they need to submit a new request to the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is OneTouch Ultra Test Strips. 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.The item at issue is not directly related to the delivery of insulin. This is eligible for coverage under Part B. Your plan does not offer supplemental (additional) coverage for this item. If you purchased items that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the item. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anoro Ellipta 62.5-25 microgram inhaler prescribed for chronic obstructive pulmonary disease. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the 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 Anoro Ellipta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Mycophenolate Mofetil 500 milligram tablets prescribed for immunosuppressive therapy due to the presence of myasthenia gravis. 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. Mycophenolate Mofetil is a generic drug on Tier 3 of the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the generic drugs of the same type on the lower tiers of the plans formulary to treat the noted condition have been tried and failed, or are contraindicated. 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 Promethazine Hydrochloride 25 milligram suppository prescribed every six hours as needed for gastroparesis. 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 records submitted at the reconsideration level.The documentation shows the doctor prescribed Promethazine Hydrochloride 25 milligram suppository to treat the enrollees gastroparesis. 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 Promethazine Hydrochloride 25 milligram suppository.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollee requested Fluorouracil-Calcipotriene cream 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 the Fluorouracil-Calcipotriene cream is a compounded drug and each ingredient is reviewed individually. Medicare Part D does not cover non-prescription drugs. We reviewed Food and Drug Administration (FDA)-approved sources for the drugs classification or determined from other available resources that the drugs are non-prescription or over-the-counter (OTC) drugs. Therefore, the Calcipotriene, Propylene Glycol solution, Ethoxy Diglycol, BHRT base cream, and Pen Cream ingredients are not eligible for Part D coverage. The Fluorouracil is a powder and not covered by the Part D plan. The active ingredients within the compounded drug are not eligible for Part D coverage. Therefore, we determined the plan is not required to cover the Fluorouracil-Calcipotriene cream or provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Xifaxan 550 milligram tablets. 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.The submitted documentation does not include medical records. A request for information was sent to the prescriber; however, no further documentation was received. 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 a request for coverage of Dupixent 300 milligram per 2 milliliter subcutaneous injection syringe prescribed for atopic dermatitis. 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. Dupixent 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 of 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 Invokana 300 milligram tablet prescribed for diabetes. 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 aske the prescriber to send us information regarding the Enrollee's condition. We also asked for medical records or other documentation to show why the medication is 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 does not support why other drugs on the plans formulary would not work. A physician reviewed your appeal and determined that the plan is not required to cover Invokana.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Alendronate Sodium 70 milligram tablet prescribed for an unknown diagnosis. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available. The record includes illegible pharmacy receipts. We attempted to request a case file (two fax requests and one phone call request without success). Therefore, we are unable to determine that the enrollee paid for the Alendronate Sodium or that Alendronate Sodium was prescribed for a medically accepted indication.A physician reviewed your appeal and determined that the plan is not required to reimburse you for the Alendronate Sodium.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amlodipine 5 milligram tablet prescribed for an unknown diagnosis. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available. The record includes illegible pharmacy receipts. We attempted to request a case file (two fax requests and one phone call request without success). Therefore, we are unable to determine that the enrollee paid for the Amlodipine or that Amlodipine was prescribed for a medically accepted indication.A physician reviewed your appeal and determined that the plan is not required to reimburse you for the Amlodipine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Famotidine 50 milligram tablet prescribed for an unknown diagnosis. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available. The record includes illegible pharmacy receipts. We attempted to request a case file (two fax requests and one phone call request without success). Therefore, we are unable to determine that the enrollee paid for the Famotidine or that Famotidine was prescribed for a medically accepted indication.A physician reviewed your appeal and determined that the plan is not required to reimburse you for the Famotidine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gabapentin 300 milligram capsule prescribed for an unknown diagnosis. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available. The record includes illegible pharmacy receipts. We attempted to request a case file (two fax requests and one phone call request without success). Therefore, we are unable to determine that the enrollee paid for the Gabapentin or that Gabapentin was prescribed for a medically accepted indication.A physician reviewed your appeal and determined that the plan is not required to reimburse you for the Gabapentin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrocortisone 2% cream prescribed for an unknown diagnosis. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available. The record includes illegible pharmacy receipts. We attempted to request a case file (two fax requests and one phone call request without success). Therefore, we are unable to determine that the enrollee paid for the Hydrocortisone or that Hydrocortisone was prescribed for a medically accepted indication.A physician reviewed your appeal and determined that the plan is not required to reimburse you for the  Hydrocortisone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ibuprofen 600 milligram tablet prescribed for an unknown diagnosis. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available. The record includes illegible pharmacy receipts. We attempted to request a case file (two fax requests and one phone call request without success). Therefore, we are unable to determine that the enrollee paid for the Ibuprofen or that Ibuprofen was prescribed for a medically accepted indication.A physician reviewed your appeal and determined that the plan is not required to reimburse you for the Ibuprofen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pravastatin Sodium 20 milligram tablet prescribed for an unknown diagnosis. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available. The record includes illegible pharmacy receipts. We attempted to request a case file (two fax requests and one phone call request without success). Therefore, we are unable to determine that the enrollee paid for the Pravastatin Sodium or that Pravastatin Sodium was prescribed for a medically accepted indication.A physician reviewed your appeal and determined that the plan is not required to reimburse you for the Pravastatin Sodium.