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

At issue is Buprenorphine Hydrochloride 8 milligram sublingual tablet prescribed for chronic pain. 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. Buprenorphine Hydrochloride 8 milligram sublingual tablet is prescribed for chronic pain. However, Medicare approved compendia do not support the use of this drug for this condition.  A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Novolog 70-units/milliliter-30-units/milliliter flexpen prescribed for the enrollees condition. The Part D plan denied the 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.Novolog is a biologic on Tier 3 of the plans formulary. There are no other biologics of the same type on the lower cost sharing tiers. Therefore, this biologic is not eligible for a tiering exception.A physician reviewed the 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 Mycophenolate Mofetil 500 milligram tablet to treat antisynthetase syndrome and interstitial lung disease not associated with system sclerosis. 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 Mycophenolate Mofetil was prescribed to treat antisynthetase syndrome and interstitial lung disease not associated with system sclerosis. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of methylprednisolone sodium succinate 125 milligram tablets. The Part D plan denied the request because the drug was being prescribed for 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. The documentation indicates that methylprednisolone sodium succinate has been prescribed for the treatment of coronavirus disease 2019 (COVID-19) infection. The Medicare approved compendia, American Hospital Formulary Service Drug Information (AHFS-DI) and DrugDex Information System, do not contain any citations to support the use methylprednisolone sodium succinate for the treatment of COVID-19 infection. However, AHDS-DI references the American Society of Health-System Pharmacists (ASHP) COVID-19 Resource Center for information on the use of various therapies for the treatment of COVID-19 infections. Regarding systemic corticosteroids, such as methylprednisolone sodium succinate, the AHSP notes that the National Institutes of Health (NIH) COVID-19 Treatment Guidelines Panel recommends against the use of dexamethasone or other corticosteroids in non-hospitalized patients with mild to moderate COVID-19 or in hospitalized patients with COVID-19 who do not require supplemental oxygen. The prescriber has indicated that the enrollees COVID-19 symptoms are mild and that the enrollee is currently not hospitalized and does not require supplements oxygen. Therefore, it has been determined that the requested 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: Favorable

At issue is Droxidopa 100 milliram tablet prescribed three times per day for neurogenic orthostatic hypotension. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The medical records show the doctor prescribed Droxidopa to treat the enrollees neurogenic orthostatic hypotension. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The records show the enrollee had neurogenic orthostatic hypotension, tried and failed the medication Midodrine, and Fludrocortisone was contraindicated due to heart failure. The documentation provided shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed the appeal and determined that the plan is required to cover Droxidopa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a direct member reimbursement request for Ondansetron ODT 4-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 contain 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 reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Silodosin 8-milligram capsules prescribed for benign prostatic hyperplasia. 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 all formulary alternatives were tried and failed or were contraindicated. However, we did not receive the requested information.The submitted documentation did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed the appeal and determined that the plan is not required to cover Silodosin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Somatuline Depot 90 milligram/0.3 milliliter solution prescribed for silent corticotroph pituitary macroadenoma. 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. Somatuline Depot 90 milligram/0.3 milliliter solution is prescribed for pituitary macroadenoma as a continued therapy that is given to the enrollee along with Cabergoline. The enrollee has had stable disease and the prescriber would like to continue this therapy. However, Medicare approved compendia do not support the use of this drug for this condition.  A physician reviewed your appeal and determined that the plan is not required to cover Somatuline Depot.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Mekinist 2-milligram tablet to treat malignant melanoma left upper limb including shoulder. 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 Medicare-approved compendium contains citations that support the use of the requested drug, as prescribed, for treatment of the noted condition. There is peer-reviewed, clinically relevant, medical literature from an approved journal (Lancet Oncology) that support this appeal. The documentation satisfies the plans coverage criteria.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Albendazole 200 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the request.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 submitted documentation shows Visory Health discount card was applied to the purchase of the requested drug. According to the RX discount card website (https://www.visoryhealth.com), the discount cards are intended for out-of-pocket paying consumers and may not be used with commercial health plans or any federal or state funded health care program, such as Medicare or Medicaid. When the enrollees benefit card was used, the enrollee acknowledged and agreed that Visory will be treated as the primary payor with respect to the medications that are purchased through the discount program. Therefore, the plan is not required to cover or provide reimbursement for the requested drug.To pursue payment, please update the insurance information at the pharmacy where drugs are purchased and ask to reprocess the claim through the Part D insurance plan without applying the discount.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xiidra solution 5% prescribed for dry eye, epiphora, and nasoacrimal duct obstruction. 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 the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Xiidra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vemlidy 25-milligram tablet 90-tablets/90-days to treat chronic hepatitis B. The Part D plan denied the request. We received a reconsideration 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.The plan limits the amount of Vemlidy to a supply of 30-tablets/30-days for members. The plan's benefit states that you are limited to a supply of 30 days at retail and mail for specialty drugs.  Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that quantity limit criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20-milligram capsule to treat circadian rhythm sleep disorder, free running type (Non-24). 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.We asked your prescriber to send us a prescriber statement, answers to prior authorization coverage criteria, and medical records. However, we did not receive the documentation.The 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 Cosentyx 150 milligrams per milliliter prescribed 300 milligrams weekly for five weeks then every two weeks for hidradenitis suppurativa. 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 Cosentyx to treat the enrollees hidradenitis suppurativa. However, the Medicare approved compendia do not support the use of this drug for your diagnosis. A physician reviewed the appeal and determined that the plan is not required to cover Cosentyx.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsules prescribed for insomnia. 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 diagnosis and a prescriber statement to support the enrollee met the plans prior authorization coverage criteria. However, we did not receive the requested information.The submitted documentation indicates the prescriber ordered the drug at issue for the enrollees noted condition. On appeal, documentation was submitted to indicate the prescribed diagnosis was circadian rhythm sleep disorder, free running type. However, there were no medical records submitted to support a change in diagnosis. 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 Cosentyx 300 milligram pen injector prescribed for moderate-severe plaque psoriasis. 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 records submitted at the reconsideration level. The medical records show Cosentyx was prescribed to treat moderate-severe plaque psoriasis. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Cosentyx. 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 Testosterone 50 milligrams per 5 grams (1 percent) gel prescribed for the enrollees condition. The Part D plan denied the appeal 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.Testosterone 50 milligrams per 5 grams (1 percent) gel is a generic drug on Tier 3 of the plans formulary. There are no generic drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the 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 Etodolac 600 milligram extended release tablet. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We requested additional information from the prescriber to establish medical necessity of this non-formulary drug and confirm that the requested drug is being used for a medically accepted indication. We did not receive information that could answer these medical necessity issues. 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 cover Etodolac.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hematex 150-milligram tablets prescribed for anemia. 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 determined that the plan is not required to cover Hematex because it is an over-the-counter medication. Nonprescription or over-the-counter drugs are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methylphenidate HCL 27 milligram tablet prescribed for attention-deficit hyperactivity disorder. 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.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the documentation does not support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Methylphenidate HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Mavenclad 10-milligram tablets prescribed for multiple sclerosis. 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 did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed the appeal and determined that the plan is not required to cover Mavenclad.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate 5 milligram tablets prescribed as directed for blepharospasm. 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 to treat your blepharospasm. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligram tablet prescribed for bacterial intestinal infection and small intestinal bacterial overgrowth. 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 Xifaxan was prescribed to treat bacterial intestinal infection and small intestinal bacterial overgrowth. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Hetlioz 20-milligram capsules prescribed for circadian rhythm sleep disorder. 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. We received additional information and included it in the review.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 Belbuca 75-microgram Film to treat chronic pain syndrome. 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 Entresto 24 milligram-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 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.Entresto 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.