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

At issue is Percocet 7.5-325 milligram oral tablet prescribed daily for chronic pain syndrome. 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. We received the documentation and included it in our review.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 Percocet.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Doxepin Hydrochloride 10 milligram capsules to treat insomnia.We performed an independent and de novo review. We reviewed all documentation submitted.The record shows the plan has approved the request for Doxepin Hydrochloride 10 milligram capsules. The requested drug has been approved coverage under Medicare Part D from April 8, 2021, through June 7, 2022.The QIC has determined that the Medicare Part D plan has approved Doxepin Hydrochloride 10 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

 At issue is Acyclovir 5% cream prescribed for herpes viral infection, unspecified. 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 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 Enrollees doctor prescribed herpes viral infection, unspecified and states the cream will be used in addition to the tablet as taking a tablet alone has not been successful. 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. Your prescriber does not state why all 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 Acyclovir 5% cream.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metoprolol Succinate Extended Release 25 milligram tablets 540 tablets per 90 days prescribed to treat atrial fibrillation. 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. Your prescriber requests Metoprolol Succinate Extended Release 25 milligram tablets 540 tablets per 90 days and states the Enrollee requires a 75 milligram dose. However, the plan has a quantity limit of 60 tablets per 30 days. The medication in question is suppled in 200, 100, 50, and 25 milligram tablets. There is no documentation of why the Enrollee cannot take a combination of 50 and 25 milligram tablets at 60 each per 30 days. The documentation does not support why an exception to the plans quantity limit is medically necessary.  A physician reviewed your appeal and determined that the plan is not required to cover Metoprolol Succinate Extended Release 25 milligram tablets at 540 tablets per 90 days as the drug amount exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Sodium 1 percent gel prescribed as directed for testicular pain, unspecified. 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 Diclofenac Sodium to treat your testicular pain, unspecified. 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 Diclofenac Sodium.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cresemba 186 milligram capsule prescribed for prevention of pulmonary aspergillosis infections in patients who are immunocompromised. 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 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 Enrollees doctor prescribed Cresemba 186 milligram capsule for prevention of pulmonary aspergillosis infections. 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 Cresemba.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Methenamine Hippurate 1 gram tablets prescribed for recurrent urinary tract infections. 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. Methenamine Hippurate is a generic 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 to our request. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the generic drugs 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 Estradiol 0.05 mg/24 hour patch prescribed for endometrial hyperplasia with uterine prolapse. 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 Estradiol was prescribed for endometrial hyperplasia with uterine prolapse 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 Estradiol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Clobazam 10 milligram tablets prescribed for seizure disorder. 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 prescriber has noted at reconsideration that the enrollee does have Lennox-Gastaut syndrome. However, no medical records were submitted to validate the diagnosis of Lennox-Gastaut syndrome. Lennox-Gastaut syndrome is a complex, rare, and severe childhood-onset epilepsy and it is the only medically accepted indication for the use of Clobazam listed in the Medicare approved compendia. During this review, a request was submitted to the prescriber to submit medical records to validate the enrollees diagnosis. The prescriber responded and submitted medical records. However, while the medical records support a seizure disorder due to the presence of Dravet syndrome, they do not support the diagnosis of Lennox-Gastaut syndrome. Although Dravet syndrome and Lennox-Gastaut syndrome are two serious epileptic syndromes, the diagnoses are not interchangeable. Therefore, the submitted medical records support that Clobazam is being prescribed for management of seizures due to the presence of Dravet syndrome. Subsequently, 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 Mavyret 100-40 milligram tablets prescribed as directed for chronic hepatitis C infection. 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 Mavyret.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Modafinil 100 milligram tablets prescribed as directed for chronic fatigue syndrome secondary to mitochondrial myopathy. 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 Modafinil to treat your chronic fatigue syndrome secondary to mitochondrial myopathy. 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 Modafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrocodone-Acetaminophen 7.5-325 milligram tablets prescribed for the enrollees condition for a tiering exception request.  The case was auto-forwarded by the plan.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.Hydrocodone-Acetaminophen is a generic drug on Tier 4 of the plans formulary. The prescriber did not address why the drugs available on the lower tiers of the plans formulary would not work. 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 Entresto 24-26 milligram tablet. 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 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. Entresto 24-26 milligram tablet 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 a prior authorization request for Zolpidem Tartrate 5 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 or a supporting statement. 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 formulary exception request for Breztri Aerosphere 160-9-4.8 microgram inhaler prescribed for chronic obstructive pulmonary disease. The case was auto-forwarded by the plan.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 on hand did not include a prescriber statement. A request for information was sent to the prescriber. The prescriber submitted a supporting statement and medical records. 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 Breztri Aerosphere.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Nexletol 180 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 diagnosis initially provided by the prescriber to the Part D plan was mixed hyperlipidemia. However, the Medicare approved compendia do not contain any citations to support the use of Nexletol for the treatment of mixed hyperlipidemia.At reconsideration, the prescriber has changed the diagnosis and noted that the enrollee has a diagnosis of heterozygous familial hypercholesterolemia, with heart disease on both sides of the family. However, no medical records have been submitted to validate the change in diagnoses. Therefore, there is insufficient documentation to determine if the requested drug is being prescribed for a medically accepted indication. As such, 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 the requested drug.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Oxycodone-Acetaminophen 10-325 milligram tablets, 127 tablets per 30 days.  The case was auto-forwarded by the plan.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. During this review, a request was submitted to the prescriber to address the coverage of this medication and to submit a prescriber statement of medical necessity and supporting medical records.Progress notes from a physicians office visit have been submitted that indicate the enrollee is being treated for moderate to severe chronic pain due to multiple chronic conditions, which is a medically accepted indication outlined in the Medicare approved compendia. The Part D plan has no prior authorization requirements or step therapy requirements for the coverage of the requested drug. Additionally, the amount of medication being requested does not exceed the plans quantity limit for this drug of 360 tablets 30 days.Therefore, the documentation supports that the medication is being used for a medically accepted indication, there are no other requirements for coverage of the drug by the plan, and the quantity limit has not been exceeded. Therefore, coverage for the drug can be allowed. A physician reviewed the appeal and determined that the plan is required to cover the Oxycodone-Acetaminophen 10-325 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a direct member reimbursement request for Oxycodone-Acetaminophen 5-325 milligram tablets. 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 submitted documentation does not include medical records. As it cannot be determined that the drug was prescribed for a medically accepted indication, reimbursement cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollee requested Insulin Lispro 100 unit/milliliter vial prescribed for diabetes. 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 Insulin Lispro is being administered through an infusion pump in the home for treatment of diabetes. Medicare law specifically excludes coverage for any drug for which payment would be available under Part A or Part B of Medicare for that individual. 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 drug is eligible under Medicare Part B. Therefore, the Part D plan is not required to cover Insulin Lispro. 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 Methylphenidate Hydrochloride 5 milligram tablet, a quantity of 60 tablets per 30 days. At initial determination and redetermination the diagnosis of other hypersomnia was given. The Part D plan denied the request stating that the provided diagnosis is 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.At reconsideration level a diagnosis of Parkinsons related fatigue was given. We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records and other documentation to show why the enrollee needed this medication. We did not receive the documentation requested. Specifically, no medical records were provided in the case for review. At this time, the diagnoses of other hypersomnia and Parkinsons related fatigue were considered. However, the Medicare approved compendia do not support the use of this drug for these diagnoses/conditions.A physician reviewed your appeal and determined that the plan is not required to cover Methylphenidate Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vemlidy 25 milligram tablet, a quantity of 60 tablets per 60 days prescribed for chronic hepatitis B virus infection. 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 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 and other documentation to show why the enrollee needed this medication. We did not receive the documentation requested. Specifically, no medical records were provided in the case for review.The documentation indicates that the doctor prescribed Vemlidy to treat the enrollees chronic hepatitis B virus infection. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition, as it is indicated that enrollee does not having compensated liver disease. A physician reviewed your appeal and determined that the plan is not required to cover Vemlidy.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tysabri 300 milligram/15-milliliter concentrate prescribed for unknown diagnosis and frequency. The Part D plan denied the request. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. The documentation shows a request for Tysabri 300 milligram/15-milliliter concentrate to treat an unknown condition. We reached out to the plan to obtain further documentation including the name of the physician and the diagnosis but we did not receive a response. 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 the requested drug.
Appeal type: Prescription Drug
Decision: Favorable

The Enrollee requested Shingrix 50/0.5 milliliter injection prescribed for shingles vaccination. We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows the Enrollee received the Shingrix vaccine at the Enrollees physicians office. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. The plans Evidence of Coverage states that payment for vaccines including administration fee is required up front from the Enrollee when provided at an out of network pharmacy or provider's office. If an Enrollee pays the full cost of a prescription, the Enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The plans formulary shows the drug is covered as a Tier 3 drug. The documentation submitted includes a statement from the physicians office that shows the Shingrix vaccine and administration fee was paid in full by the Enrollee. The vaccine and administration fee for date of service August 19, 2020 was previously approved and reimbursement was allowed. Therefore, we determined that the plan is required to reimburse you for their share of the cost for the Shingrix vaccine and administration fee for date of service October 20, 2020.