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

At issue is prescribed Lokelma 10 gram packet for hyperkalemia. 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. We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. The medical records submitted show the doctor prescribed Lokelma 10 gram packet to treat hyperkalemia. 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 the appeal and determined that the plan is not required to cover the requested medication. 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 reimbursement for Hydrocodone-Acetaminophen 7.5-325 milligram tablets purchased on July 21, 2021, which have been prescribed for low back pain and chronic pain due to rheumatoid arthritis. The Part D plan denied the request stating that the drug is limited to a 90-day supply. 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 ordered 180 tablets per 90 days of Hydrocodone-Acetaminophen 7.5-325 milligram tablets. While the plan stated in the denial letter that the drug is limited to a 90-day supply, the plans formulary shows that Hydrocodone-Acetaminophen is actually limited to a recurring 30-day supply. An exception to the quantity limit criteria is not supported. A physician reviewed the appeal and determined that the plan is not required to cover more than a recurring 30-day supply of the requested drug. Therefore, reimbursement is not covered for the drug already purchased.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Magnesium Citrate oral solution 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 determined that the plan is not required to cover Magnesium Citrate because it is an over-the-counter drug. 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: Favorable

At issue is a prior authorization request for Humulin R 500 units/milliliter solution prescribed for type 2 diabetes mellitus with diabetic polyneuropathy. 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 address the plan's prior authorization coverage criteria. We received the requested information and included it in the review.The submitted documentation indicates the prescriber ordered the medication at issue for the enrollees condition. Furthermore, the prescriber submitted a statement to indicate the enrollee requires more than 200 units of U-100 insulin per day. The submitted medical records support the biologic drug at issue will not be used as a continuous subcutaneous infusion. The submitted documentation supports the enrollee has met the plans prior authorization coverage criteria.A physician reviewed the appeal and determined that the requested biologic drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Rybelsus 3 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.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 for Zolpidem Tartrate 12.5 milligram tablets 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 and a prescriber statement to support the need 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 is ordering a quantity of 30 tablets per 30 days. The plan has a quantity limit of 90 tablets per 365 days for the drug at issue. We did not receive documentation from the prescriber to support a quantity greater than the plans allowance. Therefore, a quantity limit exception cannot be granted and the amount approved by the plan is upheld.Therefore, the plan is not required to cover the requested drug for a quantity limit exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Donnatal 16.2 milligram tablets prescribed for chronic idiopathic constipation. 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 plan denied the request for coverage of the requested drug to treat the provided diagnosis because the Medicare Part D drug plan cannot cover drugs classified as being part of the Food and Drug Administration Drug Efficacy Study Implementation (DESI) program. These drugs are considered to be less than effective per review.We determined that the plan is not required to cover the drug at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for Gammaplex 5 grams/50 milliliter vial prescribed for a demyelinating disease of central nervous system of unclear etiology. 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 Gammaplex was prescribed to treat a demyelinating disease of central nervous system of unclear etiology. The prescriber submitted an office note dated 7/8/2021 as well as abstracts and an order form for the rerquested drug.  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 Gammaplex.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Lidocaine 5% patch prescribed for chronic mid and low back 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. We asked the prescriber to send us information regarding the enrollee's condition. We also asked for medical records or other documentation to show why the enrollee's needs the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the enrollee. We received the documentation and included it in our review.The documentation shows Lidocaine 5% patch was prescribed to treat chronic mid and low back pain. 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 Lidocaine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Farxiga 10 milligram tablet prescribed for chronic systolic 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 the prescriber to send us information regarding the enrollee's condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. We received the documentation and included it in our review.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, medical records and a prescriber's statement 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 Farxiga.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lenvima 10 milligram capsule to treat metastatic squamous cell carcinoma of the right tonsil. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. We received a reconsideration request. It is noted that the prescriber has submitted multiple requests to conduct a peer-to-peer review for this case. However, C2C is a qualified independent review organization that has been contracted by the Center for Medicare Management (CMS) to do independent second level appeal reviews for Part D drugs that have been denied by the Part D plans. While the Part D plans do peer-to-peer reviews, C2C has not been contracted by CMS to conduct peer-to-peer reviews. Therefore, a peer-to-peer review is not possible at this level and the case will be reviewed, as contracted. The documentation received is the same as the previously provided documents used in our decision.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 Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the request for reimbursement. 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. We determined that the plan is not required to reimburse the enrollee for the Eliquis. The record shows the enrollee requested the plan to provide reimbursement for Eliquis purchased on date of service July 30, 2021. However, the plan provided documentation indicating Eliquis is a non-formulary drug, which was not approved for coverage, as a formulary exception until August 31, 2021. Therefore, the drug was not eligible for coverage or reimbursement for date of service July 30, 2021. 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 a request for coverage of Nuedexta 20-10 milligram capsule prescribed for pseudobulbar affect. 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 Nuedexta was prescribed to treat pseudobulbar affect without multiple sclerosis or amyotrophic lateral 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 Nuedexta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sevelamer Carbonate 800 milligram tablet prescribed three time daily for hyperphosphatemia in an enrollee with chronic kidney disease. 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 Sevelamer Carbonate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mavenclad 10 milligram, 7-tablet pack prescribed as directed for multiple 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. 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 Mavenclad.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Taltz 80 milligram/milliliter auto injector prescribed as directed for moderate-severe psoriasis. 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 Taltz to treat your moderate-severe 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 Taltz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jardiance 10 milligram tablets prescribed for diabetes mellitus. 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.Jardiance is a brand drug on Tier 3 of the plans formulary. There are no other 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 Promethazine Hydrochloride 25-milligram tablet. At initial determination and redetermination no diagnosis 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 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 your prescriber to send us a prescriber statement, a medically accepted indication (diagnosis), answers to prior authorization coverage criteria, address the issues regarding this high-risk medication, and medical records. However, we did not receive the documentation.No medical records were provided by the prescriber. It could not be determined whether the requested drug was being prescribed for a medically accepted indication and met the prior authorization requirements. 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 Tradjenta 5 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. Tradjenta is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Otezla 30 milligram tablets prescribed for psoriasis. 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. 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 Tivicay 50 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. This drug is included on Tier 5 of the plans formulary. This tier is identified as a Specialty Tier. The plan is not required to grant a tiering exception for drugs available on their Specialty Tier. Therefore, a tiering exception cannot be considered.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aimovig 70 milligram/milliliter auto injector prescribed as directed for migraine without aura and with status migrainosus, not intractable. 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 Aimovig to treat your migraine without aura and with status migrainosus, not intractable. 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 Aimovig.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxybutynin CL 5 milligram extended release tablets prescribed for overactive bladder. 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.Oxybutynin CL is a generic drug on Tier 2 of the plans formulary. There are no other 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.