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

At issue is Diclofenac 1% Gel to treat polyosteoarthritis, unspecified. 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 does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan, with supporting medical documentation, would likely cause harm or not be as effective as the requested drug. 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 Buprenorphine Hydrochloride 8 milligram sublinqual tablets prescribed every 8 hours as needed for chronic pain disorder due to cervical spinal fusion, degenerative cervical disc, and intervertebral disc disease. The Part D plan denied your request stating that the drug was not used for a medically accepted indication. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any information submitted at the reconsideration level. The use of the requested drug to treat the provided diagnosis 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.  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 Nexletol 180-milligram tablet to treat unspecified hyperlipidemia. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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 use of the requested drug to treat the provided diagnosis 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

You requested Diclofenac Sodium 1% gel. 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 your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the requested documentation.You requested Diclofenac Sodium 1% gel. The Part D plan denied your request stating the prior authorization requirements were not satisfied. No medical records have been provided. Therefore, the QIC is unable to determine if this enrollee has met the criteria for a medically acceptable indication per the approved Medicare compendia.A physician reviewed your appeal and determined that the plan is not required to cover Diclofenac Sodium 1% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sivextro 200 milligram tablets prescribed for a nocardia infection. 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 does not contain medical records to support a covered diagnosis. 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 Nuzyra 150-milligram tablet to treat pulmonary mycobacterial infection due to mycobacterium abscesses. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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 use of the requested drug to treat the provided diagnosis 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 Gemtesa 75 milligram tablets prescribed to treat overactive bladder. 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 Gemtesa 75 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Shingrix (shingles vaccine). The Part D Plan denied your reimbursement request because the National Drug Code or Current Procedural Terminology Code for the vaccine was not provided, and the National Provider Identifier and Tax ID for the facility was not included. 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 vaccine. We also asked for medical records and other documentation to show why you need this vaccine. In addition, we requested the National Drug Code or Current Procedural Terminology Code for the vaccine, and the National Provider Identifier and Tax ID for the facility. We did not receive the documentation requested. The documentation shows that for the date of service of January 04, 2021, you paid $258.00, for the shingles vaccine. However, the documentation provided does not include information regarding your vaccine as requested and needed for reimbursement. We determined that the plan is not required to reimburse you for Shingrix. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.In conclusion, the decision of the QIC is unfavorable.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Aspirin 81 milligram chewable tablet prescribed while in the hospital for unknown diagnosis.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.According to Medicare rules, over-the-counter drugs are excluded from coverage under Part D. Therefore, we determined that the plan is not required to reimburse you for the Aspirin. It is noted that emergency room copays are not covered under Medicare Part D. Please submit your appeal request to the appropriate party.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Skyrizi 150 milligram Dose Kit prescribed to treat severe plaque psoriasis. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. Skyrizi was prescribed to treat severe plaque psoriasis. The drug is not on the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.A physician reviewed your appeal and determined that the plan is not required to cover Skyrizi.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Armodafinil 250 milligram oral tablet. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Armodafinil to treat your fatigue related to multiple sclerosis. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Armodafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Shingrix 50 microgram/0.5 milliliter kit. 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 vaccine. We also asked for medical records and other documentation to show why you need this vaccine. We did not receive the documentation requested.The documentation shows you are requesting reimbursement for the shingles vaccine on January 18, 2021. The plan submitted documentation that shows coverage was provided for the Shingrix vaccination. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the clinic charged you. The plan paid its share of the cost for the covered drug and you were responsible for the copay. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Eliquis 5 milligram tablets.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Eliquis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.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 reimbursement for Estradiol Versacream 12 grams, 0.1 milligram/gram prescribed as directed. 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 QIC notes this drug is a compounded drug. Therefore, we reviewed each ingredient individually.Bulk powders (that is, active pharmaceutical ingredients for compounding) do not satisfy the definition of a Part D drug and are not covered by Part D. Therefore, the Estradiol micronized powder ingredient is not eligible for Part D coverage. The plan is not required to provide reimbursement for it. This decision does not address the medical necessity of this drug. It only means that payment cannot be made under the Medicare Part D benefit.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 drug is a non-prescription or over-the-counter (OTC) drug. Therefore, the Versapro cream base ingredient is not eligible for Part D coverage. The plan is not required to provide reimbursement for it. This decision does not address the medical necessity of this drug. It only means that payment cannot be made under the Medicare Part D benefit.We determined that the plan is not required to reimburse the Estradiol Versacream.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Calcitriol 0.25 microgram prescribed for the treatment of secondary hyperparathyroidism. 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. According to Medicare rules, the requested drug cannot be approved for separate payment under Part D when it is for treatment on a patient who is receiving dialysis. Medicare records show the enrollee is actively receiving dialysis. Therefore, the Calcitriol must be billed by the renal dialysis facility. We determined that the plan is not required to cover the Calcitriol. Please submit your request for this drug through the dialysis provider.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Shingrix 50 micrograms/0.5 milliliter intramuscular suspension kit. 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 you received the Shingrix vaccine on October 20, 2020. If a vaccine is administered outside of the plans Part D pharmacy network, the provider would supply the vaccine, administer it, and then bill the beneficiary for the entire charge, including all components. The beneficiary would, in turn, submit a paper claim to the Part D sponsor for reimbursement for both the vaccine ingredient cost and administration fee. In this case, proof of payment in the form of a receipt showing the amount that you paid for the drug was not provided. Therefore, we determined that the plan is not required to reimburse you without the required documentation. Please submit proof of payment to your plan for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Adderall XR 20 milligram capsules prescribed as directed for attention deficit hyperactivity disorder. 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 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 Adderall XR.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Livalo 2 milligram tablets prescribed for mixed hyperlipidemia. 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.Livalo 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 Livalo at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Orencia 125-milligram Clickjet to treat rheumatoid arthritis. The Part D plan denied the request. The requested drug is not on the plans formulary. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. The issues raised in the prescriber statement are not supported in the Medicare approved compendia.Therefore, an exception to the plans formulary coverage criteria is not supported.Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cresemba 186-milligram capsule for fungal prophylaxis due to acute myeloblastic leukemia and bone marrow transplant. 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 use of the requested drug to treat the provided diagnosis 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 a prior authorization request for Zolpidem Tartrate 10 milligram tablets prescribed for insomnia due to metastatic breast cancer. 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 did not include a supporting statement or medical records. A request for information was sent to the prescriber. The documentation now 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 drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fosfomycin 3 grams sache prescribed to take one packet every 3 days to treat urinary tract 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 records submitted at the reconsideration level.We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the requested documentation.The prescriber indicates that several of plans alternative formulary drugs were tried and failed or could cause harm. In order to grant an exception for a drug not on the plans formulary, all alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the records do not support 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 Fosfomycin 3 grams sache.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Gabapentin 800 milligram tablets prescribed for diabetic neuropathy. The Part D plan denied the request for coverage because the amount requested exceeded the plans quantity limit. 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 submitted medical records show that the physician has prescribed Gabapentin 800 milligram tablets, two tablets to be taken three times daily, which would be a total of six tablets per day, or 180 tablets per 30 days. The plans 2021 formulary includes a quantity limit for Gabapentin 800 milligram tablets of 180 tablets per 30 days. Therefore, the amount of 800 milligram Gabapentin tablets requested has not exceeded the quantity limits of the plans current formulary.However, as outlined in the Medicare approved compendia, the maximum acceptable dosage of Gabapentin for the treatment of diabetic peripheral neuropathy is 3600 milligrams per day orally in three divided doses. The physician has requested two 800 milligram tablets to be taken three times a day, which is a total daily dosage of 4800 milligrams. The Gabapentin prescribed by the physician exceeds the maximum dose outlined in the Medicare approved compendia. Therefore, the drug, as prescribed, does not meet the requirements for a 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 Gabapentin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Basaglar Kwikpen 100 units/milliliter prescribed for the enrollees condition. 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.Basaglar Kwikpen is a brand biologic on Tier 3 of the plans formulary. There are no brand biologics of the same type on the lower cost sharing tiers. Therefore, this biologic 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.