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

You requested Lidocaine 5 percent patch prescribed as directed for hip pain and systemic lupus erythematous, unspecified. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. 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  Lidocaine 5 percent patch was prescribed for hip pain in an enrollee with systemic lupus erythematous, unspecified. 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 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 Xeljanz XR 11 milligram tablets prescribed for rheumatoid arthritis. 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 asked the prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why the enrollee needs the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the enrollee. However, we did not receive the documentation.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. 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.A physician reviewed the appeal and determined that the plan is not required to cover Xeljanz XR.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Selenium Sulfide 2.5% shampoo prescribed for seborrheic dermatitis. 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.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 the appeal and determined that the plan is not required to cover Selenium Sulfide.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Premarin 0.625 milligram/gram vaginal cream with applicators. 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.Premarin vaginal cream 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. 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 the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is butalbital-acetaminophen-caffeine 50-300-40-milligram capsule to treat Nonintractable episodic headache, unspecified headache type R51.9. 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 dated 8/9/2021 shows your doctor prescribed butalbital-acetaminophen-caffeine 50-300-40-milligram capsule to treat your Nonintractable episodic headache, unspecified headache type R51.9. However, the Medicare approved compendia do not support the use of this drug for your 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 a tiering exception request for Repatha SureClick 140 milligram per milliliter subcutaneous injection pen prescribed for hyperlipidemia in the presence of atherosclerotic cardiovascular disease. 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. Repatha SureClick is a brand drug on Tier 4 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 the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier level. The drug will continue to be covered at the Tier 4 copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Ilaris 150 milligram per milliliter vial. 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 Ilaris has been prescribed for the treatment of severe rheumatoid arthritis. 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 the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Favorable

The enrollee requested Shingrix 50/0.5 milliliter injection prescribed for shingles vaccination. We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows the enrollee received the Shingrix vaccine at the enrollees physicians office. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. The plans Evidence of Coverage states that payment for vaccines including administration fee is required up front from the enrollee when provided at an out of network pharmacy or provider's office. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The plans formulary shows the drug is covered as a Tier 1 drug. The documentation submitted includes a statement from the physicians office that shows the Shingrix vaccine and administration fee was paid in full by the enrollee. Therefore, we determined that the plan is required to reimburse the enrollee for their share of the cost for the Shingrix vaccine and administration fee for dates of service June 16, 2021 and September 16, 2021.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Norditropin FlexPro 10 milligram per 1.5 milliliter subcutaneous auto injection pen prescribed for the treatment of hypopituitarism and growth hormone deficiency. 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 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. Norditropin FlexPro is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale as to why the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Xeljanz 5 milligram tablets. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that Xeljanz has been prescribed for the treatment of hidradenitis suppurativa and pyoderma gangrenosum. 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 conditions. 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 the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Deferasirox 500 milligram soluble tablets. The Part D plan denied the request for coverage because the plans prior authorization requirements were not met.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 medical records and prescriber statement submitted at reconsideration validate that all of the plans prior authorization requirements, except for one, for coverage of Deferasirox have been satisfied. The medical records show that the enrollee is being treated for transfusion hemosiderosis, which is a medically accepted indication for the drug as outlined in the Medicare approved compendia. It is noted that the enrollee has chronic iron overload due to sickle cell disease and the need for multiple blood transfusions. The submitted laboratory results from August 4, 2021, show that the enrollees serum ferritin level is greater than 1000 micrograms per liter and the enrollees platelet level is not less than 50,000. The documentation also supports that the enrollee does not have poor performance status, does not have an advanced malignancy, and does not have myelodysplastic syndrome. The only prior authorization requirement that is not answered by the submitted medical records is whether the enrollees creatinine clearance level is not less than 40. During this review, the prescribers office was contacted by phone to obtain the enrollees latest creatinine clearance level. Spoke with a registered nurse at the prescribers office and she stated that the enrollees creatinine clearance level on August 4, 2021, was 124.79. Therefore, it has been confirmed that the enrollees creatinine clearance level is not less than 40. As such, all of the plans prior authorization requirements have been met. The plan has no quantity limit or step therapy requirements for the drug. 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 Dupixent 300 milligram/2 milliliter syringe prescribed for bullous pemphigoid. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The 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

The enrollee requested Oxycodone-Acetaminophen 10-325 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the enrollees reimbursement 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 plan submitted documentation that shows the enrollee paid full price for the Oxycodone-Acetaminophen 10-325 milligram tablet at a net-work pharmacy. According to your plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus your required co-payment amount, and the difference between what the plan normally pays for the drug and what the pharmacy charged you. If you pay the full cost of a prescription, then you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, the plan provided documentation showing a claim for date of service April 13, 2021 was processed prior to coverage criteria being met. Therefore, further reimbursement is not required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Transderm Scopolamine 1.5 milligram 72 hour patch prescribed for unknown diagnosis. The Part D plan denied the enrollees request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We determined that the plan is not required to cover the Transderm Scopolamine patch. The National Drug Code provided of the requested drug is not listed with the Food and Drug Administration. Therefore, the drug is excluded from coverage under Medicare Part D. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Imipramine Hydrochloride 25 milligram 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 confirm a diagnosis as the documentation was conflicting. We did not get a response. In order to establish medical necessity and confirm that the requested drug is being used for a medically accepted indication, as required by Medicare, documentation supporting a medically accepted indication are required. This information was requested from the prescriber and 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 to cover Imipramine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% ointment prescribed for chronic 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 documentation related to this case. Specifically, we asked the prescriber to submit medical records to support a covered diagnosis and a prescriber statement. We received the requested information and included it in the review.The submitted documentation indicates the prescriber ordered Lidocaine for chronic low back pain. 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 a request for coverage of Apriso 0.375 gram capsule prescribed for Crohns disease. The Part D plan denied the request because the requested drug was not listed on the plans formulary.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 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

At issue is a prior authorization request for Testosterone 1.62% gel pump prescribed for primary male hypogonadism. 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 documentation related to this case. Specifically, we asked the prescriber to submit medical records to support a covered diagnosis and a prescriber statement. We received the requested documentation and included it in the review.On original appeal, the documentation indicates the Testosterone was ordered for testicular hypofunction. The prescriber statement submitted indicates the Testosterone was ordered for a diagnosis of primary hypogonadism. The medical records submitted do not indicate a diagnosis of primary hypogonadism. The enrollee was seen for weakness due to possible hypogonadism. 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 requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Sildenafil Citrate 20 milligram tablet prescribed for pulmonary hypertension WHO group 2. 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 the 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 some documentation and included it in our review.  The prescriber sent an appeal letter dated 8/2/2021 and an echocardiogram report dated 3/25/2014 which shows pulmonary hypertension.  The echocardiogram does not state that the enrollee has Group 1 pulmonary arterial hypertension.  The prescriber was asked by the plan if the enrollee had pulmonary artery hypertension WHO group 1.  The prescriber answered, 'No.'  The prescriber provided the plan with an office note dated March 7, 2016.  The office note states that the enrollee was diagnosed with pulmonary hypertension WHO group 2 in 2012.  The prescriber did not send more recent medical records.  The documentation shows Sildenafil Citrate was prescribed to treat pulmonary hypertension, WHO group 2. 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 Sildenafil Citrate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dupixent 300 milligram/2-milliliter pen prescribed as directed for prurigo nodularis. 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 Dupixent to treat your prurigo nodularis. However, the Medicare approved compendia do not support the use of this drug for your condition. This decision does not speak to the medical necessity of this drug for your condition. This decision speaks to whether your plan is required to provide coverage under Medicare rules.A physician reviewed your appeal and determined that the plan is not required to cover Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Xtampza extended-release 27 milligram 12-hour abuse-deterrent capsules to treat chronic pain.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.Xtampza 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. 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.