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

You requested Rexulti 1 mg tablets prescribed as directed for bipolar 1 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. The documentation shows your doctor prescribed Rexulti to treat your bipolar 1 disorder. 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 Rexulti.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Tadalafil 20 milligram tablet to be taken once daily. The Part D plan denied the request because drugs used to treat erectile dysfunction are excluded from coverage under Medicare Part D. 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 does not indicate the Tadalafil is being prescribed for erectile dysfunction. The documentation indicates that Tadalafil is being prescribed for the treatment of benign prostatic hyperplasia with lower urinary tract symptoms, which is an accepted indication outlined in the approved Medicare compendia. However, the dosage guidelines in the compendia for Tadalafil list a dosage of 5-milligrams orally once daily in the treatment of benign prostatic hyperplasia. There is no citation in the compendia to support the prescribed dosage of 20-milligrams daily. Therefore, the approved Medicare compendia do not support the Tadalafil at the requested dose. As such, the 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: Unfavorable

At issue is Lidocaine 2-percent gel prescribed for bowel preparatory routine due to neurogenic bowel. The Part D plan denied the request. Of note, the prescriber ordered a quantity of medication greater than the plan's allowance.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.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement. We received additional information and included it in the review.The submitted documentation indicates the prescriber ordered the drug at issue for the enrollees noted condition. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed. A quantity limit exception cannot be granted.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 Esterified Estrogens-Methyltesosterone to treat symptomatic post procedural ovarian failure. 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. The documentation shows Esterified Estrogens-Methyltesosterone was prescribed to treat symptomatic post procedural ovarian failure. 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 Esterified Estrogens-Methyltesosterone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Zolpidem Tartrate 5-milligram tablets prescribed for insomnia. The Part D plan denied coverage.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 records submitted at the reconsideration level. We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the enrollee satisfies the plan's prior authorization coverage criteria. However, we did not receive the requested information.The submitted documentation does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.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 Lidocaine 5 percent patch prescribed as directed for acute bilateral low back pain with left-sided sciatica. 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 also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Lidocaine 5 percent patch to treat your acute back pain. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine 5 percent patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine 5 milligram/hour patch  prescribed as directed for surgical spinal stenosis, surgical bilateral carpal tunnel and broken right ankle. 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 Buprenorphine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliquis 5 milligram tablet. 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.Eliquis is a brand drug on Tier 3 of the plans formulary. 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. Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Singulair 5-milligram chewable tablet. 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.We requested additional information from the prescriber. Specifically, we requested medical records to support a prescribed diagnosis, and a prescriber statement to support the formulary alternatives were tried and failed. However, we did not receive the requested information.The submitted documentation does not include medical records or evidence of a prescribed diagnosis. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.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 Travoprost 0.004-percent ophthalmic solution. 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.We requested additional information from the prescriber. Specifically, we requested medical records to support a prescribed diagnosis, and a prescriber statement to support the formulary alternatives were tried and failed. However, we did not receive the requested information.The submitted documentation does not include medical records or evidence of a prescribed diagnosis. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.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 quantity limit exception request for Clotrimazole 1-percent compounded cream prescribed for unspecified rash. 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 requested additional documentation from the prescriber. Specifically, we requested medical records and a prescriber statement. However, we did not receive the requested information.The submitted documentation indicates the drug at issue is a compounded drug and each ingredient is reviewed individually. Medicare Part D does not cover non-prescription drugs. Some of the ingredients within the compounded drug are over-the-counter drugs and are not eligible for Part D coverage. Therefore, we determined the plan is not required to cover the compounded drug. A quantity limit exception cannot be granted.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyvanse 40-milligram capsule to treat attention deficit hyperactivity disorder, predominantly inattentive type. The Part D plan denied the request. The requested drug is not on the plans formulary. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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.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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nitro-Bid 2% Ointment to treat Raynauds syndrome without gangrene. 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 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 Qelbree 100 milligram extended-release 24-hour capsules prescribed to treat the 69 year-old enrollee with the diagnosis of attention deficit hyperactivity disorder. The Part D plan denied the appeal 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 the doctor prescribed Qelbree 100 milligram extended-release 24-hour capsules to treat a 69 year-old enrollee with attention deficit hyperactivity disorder. However, the Medicare approved compendia, DrugDex and LexiComp, show this drug is indicated for the treatment of attention deficit hyperactivity disorder in pediatric patients 6 to 17 years of age. Therefore, the Medicare approved compendia do not support the use of this drug for adults.A physician reviewed the appeal and determined that the plan is not required to cover Qelbree 100 milligram extended-release 24-hour capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armodafinil 150-milligram tablets prescribed for multiple sclerosis-related fatigue. 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 indicates the prescriber ordered the drug at issue for the enrollees noted condition. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.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 Cimzia 200-milligrams/milliliter Subcutaneous Kit to treat rheumatoid arthritis with rheumatoid factor, unspecified. The Part D plan denied the request. The requested drug is not on the plans formulary. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs required by the plan, 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 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 quantity limit exception for Buprenorphine Hydrochloride/Naloxone Hydrochloride 2-milligram/0.5-milligram sublingual tablets (112 tablets/30 days) prescribed for opioid dependence, uncomplicated. 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.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the medical necessity for a quantity of supplies greater than the plans allowance. However, we did not receive the requested information.The submitted documentation indicates the prescriber ordered the requested drug for the enrollees noted condition. The prescriber ordered a quantity of 112 sublingual tablets per 30 days. The plan has a quantity limit restriction of 90 sublingual tablets per 30 days. The submitted documentation does not indicate that a higher strength dosage of the same medication would be ineffective in treating the enrollees condition. Therefore, a quantity limit exception cannot be granted and the amount approved by the plan is upheld.The plan is not required to cover the requested drug for a quantity limit exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5-percent patch prescribed for low back pain. 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.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement. However, we did not receive the requested information.The submitted documentation indicates the prescriber ordered the drug at issue for the enrollees noted condition. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xeljanz XR 11 milligram 24-hour tablet prescribed as directed for atopic dermatitis and erosive 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. The documentation shows your doctor prescribed Xeljanz XR to treat your atopic dermatitis and erosive arthritis. 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 Xeljanz XR.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methylphenidate Hydrochloride 10-milligram tablet. At initial determination and redetermination the diagnosis of hypersomnia, unspecified and obstructive sleep apnea was given. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 narcolepsy without cataplexy was given. However, your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ondansetron Hydrochloride 4 milligram orally disintegrating tablet prescribed every six hours for nausea, heartburn, and other gastritis. 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 the prescriber ordered Ondansetron Hydrochloride to treat the enrollees nausea, heartburn, and other gastritis. However, the Medicare approved compendia do not support the use of this drug for these diagnoses. A physician reviewed the appeal and determined that the plan is not required to cover Ondansetron Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fluticasone 50 microgram spray prescribed for unknown diagnosis. The Part D plan denied the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged to the enrollee at the point of sale. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges. We determined the copay was calculated correctly, based on the pharmacy price of the drug and the enrollees cost share stage. Therefore, no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jardiance 25 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged to the enrollee at the point of sale. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges. We determined the copay was calculated correctly, based on the pharmacy price of the drug and the enrollees cost share stage. Therefore, no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Levocetirizine 5 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the claim for the requested drug was approved and copayment was charged to the enrollee at the point of sale. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charges. We determined the copay was calculated correctly, based on the pharmacy price of the drug and the enrollees cost share stage. Therefore, no further reimbursement is required by the plan.