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

You requested Aspirin EC 325 milligram tablet quantity of 2 for unknown diagnosis.We received the case to perform an independent and de novo review. We reviewed all documentation submitted.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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Calcium Carbonate 200(500) milligram chewable tablet quantity of 1 for unknown diagnosis.We received the case to perform an independent and de novo review. We reviewed all documentation submitted.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 Calcium Carbonate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested DOK 100 milligram capsule quantity of 2 for unknown diagnosis.We received the case to perform an independent and de novo review. We reviewed all documentation submitted.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 DOK.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Polyethylene Glycol 17 gram powder pack quantity of 1 for unknown diagnosis.We received the case to perform an independent and de novo review. We reviewed all documentation submitted.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 Polyethylene Glycol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Senna-S 8.6-50 milligram tablet quantity of 2 for unknown diagnosis.We received the case to perform an independent and de novo review. We reviewed all documentation submitted.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 Senna-S.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tylenol 325 milligram tablet quantity of 9 for unknown diagnosis.We received the case to perform an independent and de novo review. We reviewed all documentation submitted.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 Tylenol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dupixent 300 milligram per 2 milliliter injection. 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 prescriber statement and medical records show your doctor prescribed Dupixent to treat your pruritus. 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 Dupixent. The off-formulary requirements were not addressed because the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nortriptyline Hydrochloride prescribed four times daily for an unknown diagnosis. The Part D plan did not make a decision.We received a 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 plan reprocessed claims for the Nortriptyline Hydrochloride and adjusted the amount due to a change in your Low Income Subsidy copayment level. We determined that the plan correctly applied the low-income subsidy (LIS) benefit to which you were entitled.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Taltz 80-milligrams/milliliter to treat psoriasis vulgaris. 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. 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

You requested Metolazone 5 milligram tablets prescribed to treat acute congestive heart failure. 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 this medication. The prescriber failed to submit all of the requested documentation.The documentation shows Metolazone 5 milligrams was prescribed to treat acute congestive heart failure. The plan denied because the requested drug was not on the plans formulary. However, there were no medical records submitted supporting your condition. The QIC is unable to determine if your condition is a medically-accepted indication to support the use of the requested drug.A physician reviewed your appeal and determined that the plan is not required to cover Metolazone 5 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Oxycodone Hydrochloride 20 milligram tablets 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. 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 documentation requested.The documentation does not include medical records showing why you were prescribed Oxycodone Hydrochloride. It could not be determined whether the requested drug was prescribed for a medically accepted indication. 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 Oxycodone Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Butalbital-Acetaminophen-Caffeine 50-325-40 milligrams to treat your condition. 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 this medication. We did no receive the requested documentation.You requested Butalbital-Acetaminophen-Caffeine 50-325-40 milligrams for your condition. However, there were no medical records submitted supporting your condition. The QIC is unable to determine if your condition is a medically-accepted indication to support the use of the requested drug.A physician reviewed your appeal and determined that the plan is not required to cover Butalbital-Acetaminophen-Caffeine 50-325-40 milligrams.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is prescribed Androderm 4 milligram per 24 hour patch. 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.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 documentation requested.The documentation shows Androderm was prescribed to treat late-onset (age-related) hypogonadism. 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 Androderm. 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 a request for coverage of Epclusa 400-100 milligram tablets prescribed for chronic hepatitis C infection. 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 plan has prior authorization requirements that have to be satisfied before covering Epclusa. During this review, a request was submitted to the prescriber to address the plans coverage criteria for the medication and to provide supporting medical records. However, the prescriber did not respond to the request. The submitted documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Januvia 100 milligram tablet prescribed for diabetes. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Januvia 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Avycaz 2.5 (2-0.5) grams intravenous solution to treat acute sinusitis. 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 Sildenafil 100 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.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 documentation requested.There was no diagnosis given at initial determination. No medical records were submitted for review. Therefore, it cannot me determined if the requested drug was prescribed for a medically accepted indication supported by the Medicare approved compendia.A physician reviewed your appeal and determined that the plan is not required to cover Sildenafil. The prior authorization requirements were not addressed because the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Testosterone 25 milligram Gel Pack prescribed for secondary hypogonadism. 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 Testosterone Gel Pack for secondary (hypogonadic) hypogonadism. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation includes multiple laboratory studies with testosterone levels, a low level was measured prior to starting medication. Also there is a detailed history submitted that supports prior use and symptoms returning when stopping the Testosterone. He had resection of a pituitary macroadenoma which supports the diagnosis of secondary hypogonadism. The prior authorization requirements were met. A physician reviewed your appeal and determined that the plan is required to cover Testosterone Gel Pack.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Inspra 25 milligram tablets prescribed for hypertension with persistent proteinuria. 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.Inspra is not included in the plans formulary. The prescriber has not sufficiently addressed why all the alternative medications that are included in the plans formulary to treat the noted condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ozempic 0.25 milligram or 0.5 milligram pen-injector prescribed weekly for obesity. 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 Ozempic to treat your obesity with associated pre-diabetes. 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 Ozempic.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gleostine 100 milligram capsules prescribed as directed for the treatment of brain cancer. 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, Part D drug plans do not cover drugs produced by a manufacturer who does not participate in the Medicare Gap Discount Program. The Center for Medicare and Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. According to the May 2021 published list, the manufacturer of Gleostine has not signed the agreement and does participate in the Medicare Gap Discount Program. We reviewed your appeal and determined that the plan is not required to cover Gleostine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Buprenorphine Hydrochloride 8 milligram sublingual 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 Buprenorphine Hydrochloride sublingual tablets have been prescribed for the treatment of chronic pain. 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 your appeal and determined that the plan is not required to cover the Buprenorphine Hydrochloride sublingual tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine Hydrochloride 10 milligram prescribed at bedtime for spondylosis. 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 Cyclobenzaprine Hydrochloride to treat your spondylosis. 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 Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Freestyle Libre 14 day glucose sensor prescribed for the diagnosis of diabetes mellitus. 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 determined that the plan is not required to Freestyle Libre 14 day sensor because it is not considered a medical supply directly associated with the injection of insulin. Although, this drug is not covered under Part D, it may be covered under Part B. Please submit your request to Medicare Part B. 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 prescribed Skyrizi 150 milligram syringe. 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.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 received the documentation and included it in our review.Your medical records show your doctor prescribed Skyrizi to treat your plaque psoriasis. 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 Skyrizi. 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

You requested Amitriptyline HCL 25 milligram tablets prescribed to treat insomnia. 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 Amitriptyline HCL 25 milligram tablets to treat insomnia. The Part D plan denied your request stating that the prior authorization requirements were not satisfied. 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 Amitriptyline HCL 25 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tadalafil 20 milligram oral tablets prescribed. 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. 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 documentation requested.There was no diagnosis given at initial determination. No medical records were submitted for review. Therefore, it cannot be determined if the requested drug was prescribed for a medically accepted indication supported by the Medicare approved compendia.A physician reviewed your appeal and determined that the plan is not required to cover Tadalafil. Prior authorization requirements were not addressed because the requested drug is not eligible for coverage under the Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate Hydrochloride 10 milligram tablets prescribed as directed for chronic fatigue unspecified and major depressive disorder single episode. 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 Methylphenidate Hydrochloride to treat your chronic fatigue unspecified and major depressive disorder single episode. 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 Methylphenidate Hydrochloride.