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

At issue is Testosterone 10-milligrams/Actuation Gel to treat low testosterone levels (other unspecified abnormal findings of blood chemistry, R79.89). 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 Testosterone 10-milligrams/Actuation Gel to treat your low testosterone levels. 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

The enrollee requested Dexcom G6 Sensor prescribed for diabetes, type 2 with hyperglycemia. 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 determined that the plan is not required to cover the Dexcom G6 Sensor because it is not considered a medical supply directly associated with the injection of insulin. Although, this supply 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 supply. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Northera 100-milligram capsule to treat neurogenic orthostatic hypotension due to light chain amyloidosis. 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 Northera to treat your neurogenic orthostatic hypotension due to light chain amyloidosis. 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

The enrollee requested Vitamin D (Ergocalciferol) 1.25 milligram(50000 UT) capsule prescribed for unknown diagnosis. 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, drugs that fall into the category of vitamins and minerals are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover the Vitamin D. The plan indicates that supplemental coverage for the Vitamin D is not offered. This decision does not address 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 Hetlioz 20 milligram capsule prescribed daily for circadian rhythm sleep disorder, non-24-hour sleep-wake type. We have made two or more attempts to request a case file or the returned case file request form indicating no coverage determination/no redetermination.We performed an independent and de novo review. To make our decision, we reviewed the appeal carefully. We reviewed all documentation available. We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication was needed. We did not receive the documentation requested.Hetlioz was prescribed to treat the enrollees circadian rhythm sleep disorder, non-24-hour sleep-wake type. 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 Hetlioz. 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 Flector 1.3% Patch to treat other intervertebral disc degeneration, lumbar region, spondylosis without myelopathy or radiculopathy, lumbosacral region, and low back pain. 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 Flector 1.3% Patch to treat your other intervertebral disc degeneration, lumbar region, spondylosis without myelopathy or radiculopathy, lumbosacral region, and low back pain. 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 Cabenuva Suser Vial 600-milligrams/ 3-milliliters-900-milligrams/3-milliliters and 400-milligrams/2-milliliters-600-milligrams/2-milliliters to treat human immunodeficiency virus infection, to replace current stable antiretroviral regimen. 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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Wegovy 1.7 milligram/0.75 milliliter injection prescribed for obesity. 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 Wegovy because it was prescribed for weight loss. Drugs to treat anorexia, weight loss, or weight gain 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 Xeljanz 5 milligram tablets prescribed for alopecia areata. 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.The submitted documentation indicates the prescriber ordered Xeljanz for alopecia areata. 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 Bystolic 20 milligram tablets. The Part D plan denied the appeal request for a tiering exception.The QIC 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.Bystolic 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 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 Xtandi 40 milligram tablets prescribed for metastatic breast cancer. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates the prescriber ordered Xtandi for metastatic breast cancer. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. There are no Medicare approved journal articles submitted to support the use of the drug 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: Favorable

At issue is Dronabinol 5 milligram capsule prescribed twice daily for nausea and vomiting and loss of appetite related to cancer. 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 doctor prescribed Dronabinol to treat the enrollees nausea and vomiting and loss of appetite related to cancer. The prescriber states the drug is not being used as a full therapeutic replacement for intravenous dosage forms as part of a cancer regimen when used within 48 hours of chemotherapy. Therefore, the drug is eligible for coverage under Part D. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for this condition: Dronabinol is allowed for the off-label use of cancer related loss of appetite.A physician reviewed the appeal and determined that the plan is required to cover Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ozempic 0.25-0.5 milligrams per dose pen injector. 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.Ozempic 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 the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Amitriptyline/Baclofen/Cyclobenzaprine/Diclofenac/Lidocaine/Transdermal compound prescribed for unknown diagnosis. 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 determined that the plan is not required to cover the Amitriptyline/Baclofen/Cyclobenzaprine/Diclofenac/Lidocaine/Transdermal compound. According to Medicare rules, drugs that fall into the category of bulk powders do not meet the definition of a Part D drug. The Amitriptyline/Baclofen/Cyclobenzaprine/Diclofenac/Lidocaine/Transdermal compound is considered a bulk powder and therefore, is excluded from coverage under Part D. This decision does not address 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

You requested Tacrolimus 1 milligram capsules prescribed for lichen planus. The Part D plan denied your request for a tiering exception because the diagnosis did not meet the requirements of a medically-accepted indication. 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 Tacrolimus capsules were prescribed for lichen planus. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, a tiering exception cannot be considered.A physician reviewed your appeal and determined that the plan is not required to cover Tacrolimus capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Epinephrine 0.3 milligram auto-injector. 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 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. Epinephrine 0.3 milligram auto-injector 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 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 Eliquis 2.5 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 but 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 Eliquis.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Eszopiclone 1 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the additional 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. 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. In this case, the plan provided documentation showing the contracted price of the drug, minus any deductible, copay or coinsurance was correctly calculated at the point of sale to the enrollee. Therefore, we determined that the plan is not required to offer additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Fentanyl 50 microgram/HR 72HR patch prescribed for unknown diagnosis. The Part D plan denied the additional 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. 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. In this case, the plan provided documentation showing the contracted price of the drug, minus any deductible, copay or coinsurance was correctly calculated at the point of sale to the enrollee. Therefore, we determined that the plan is not required to offer additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Hydrocodone-Acetaminophen 7.5/325 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the additional 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. 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. In this case, the plan provided documentation showing the contracted price of the drug, minus any deductible, copay or coinsurance was correctly calculated at the point of sale to the enrollee. Therefore, we determined that the plan is not required to offer additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Lisinopril 10 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the additional 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. 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. In this case, the plan provided documentation showing the contracted price of the drug, minus any deductible, copay or coinsurance was correctly calculated at the point of sale to the enrollee. Therefore, we determined that the plan is not required to offer additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 1.62% gel prescribed two pumps daily for hypogonadism due to left orchiectomy. 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. This medication is not on your plan's list of medications. The prescriber has not given a clear and valid medical reason why all medications required by the plan, on that list, did not work for you. This reason has to be in the medical record with details of when you tried those medications. The reason the medications on the formulary won't work or could cause you harm have to be stated. Why the other medications required by the plan will not work must be discussed. 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 Testosterone 1.62% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fosfomycin Tromethamine 3 gram packet prescribed for prophylaxis of urinary tract infections. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates the prescriber ordered Fosfomycin Tromethamine for prophylaxis of urinary tract infections. 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 Methadone Hydrochloride 10-milligram tablet 84-tablets/14-days to treat neck and 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.The plan limits the amount of Methadone Hydrochloride to 120-tablets/30-days. The most recent office note of July 26, 2021 prescribes the dosage of 10 mg every 6 hours (4 times/day), within the plan's quantity limit. This is not consistent with the quantity ordered. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the condition or would be likely to cause harm. 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 Vascepa 1 gram capsule prescribed for type 2 diabetes mellitus. 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 the enrollees condition. We also asked for medical records or other documentation to show why you need this medication. We initially did not receive the documentation requested. We have now received the documentation and included it in our review.The doctor states the enrollee had elevated levels of triglycerides. However, the medical records do not support the prescriber statement. Without documentation, it cannot be determined if the Medicare approved compendia support the use of this drug for the enrollees condition. A physician reviewed the appeal and determined that the plan is not required to cover Vascepa.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a prior authorization request for Orgovyx 120 milligram tablets prescribed for advanced prostate cancer. 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 medical records submitted indicate the enrollee was diagnosed with prostate cancer with a Gleason score 8-9 involving all cores of the prostate. The enrollees PSA is markedly elevated, indicating advanced prostate cancer. The enrollee further has regional risk disease with suspicious lymph nodes noted. The documentation on hand indicates that the enrollee satisfies the plan's prior authorization coverage criteria.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.