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

At issue is Tinidazole 250 milligram tablets prescribed for Mycotoxin induced illness, Borreliosis, and Celiac disease. 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 Tinidazole for Mycotoxin induced illness, Borreliosis, and Celiac disease. 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 Piqray 300 milligram tablets prescribed for metastatic bladder 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 Piqray for metastatic bladder 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 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: Unfavorable

At issue is Lidocaine 5% Patch. At initial determination and redetermination the diagnosis of a closed fracture of the right wrist was given. The Part D plan denied the request. We received a reconsideration 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.At reconsideration a diagnosis of closed fracture of the upper end of the humerus was given. No medical records were provided by the prescriber to support these diagnoses. As such, the use of the requested drug to treat the provided diagnoses are off-label uses. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these conditions. 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

The enrollee requested Deplin 7.5 milligram, qty 30 prescribed for bi-polar depression. 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.According to Medicare rules, drugs that are considered a medical food are excluded from coverage under Part D. Deplin is on Medicares excluded list of drugs because it is considered a medical food. Therefore, we determined that the Part D plan is not required to cover the Deplin. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lynparza 150 milligram tablets prescribed for metastatic pancreatic 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 Lynparza for metastatic pancreatic cancer. The enrollee is using Lynparza as a third line chemotherapy agent and has disease progression. 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 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: Unfavorable

At issue is Pregabalin 100-milligram capsule to treat chronic pain left ankle. 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 use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Alogliptin 12.5 milligram tablets. The Part D plan denied the request. The plan has step therapy requirements for the drug at issue.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 prescribing physician. Specifically, we requested medical records and a physician supporting statement to support the plans step therapy requirements were met. However, we did not receive any additional 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

The enrollee requested SSKI 1 gram/milliliter solution prescribed for erythema nodosum. 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 SSKI. The plan indicates that SSKI may be covered under the Part B benefit. 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 Desipramine Hydrochloride 10 milligram tablet prescribed daily for neurosis of larynx, neurogenic cough, chronic sinusitis, chronic maxillary sinusitis, acute ethmoidal sinusitis, chronic rhinitis, nasopharyngitis, and pharyngitis. 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 Desipramine Hydrochloride to treat the enrollees neurosis of larynx, neurogenic cough, chronic sinusitis, chronic maxillary sinusitis, acute ethmoidal sinusitis, chronic rhinitis, nasopharyngitis, and pharyngitis. However, the Medicare approved compendia do not support the use of this drug for these conditions. A physician reviewed the appeal and determined that the plan is not required to cover Desipramine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Shingrix 50 microgram/0.5 milliliter injection 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.Shingrix is a biologic on Tier 3 of the plans formulary. There are no 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 Sildenafil 25 milligram tablets prescribed to treat pulmonary hypertension. The Part D plan denied the appeal request.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.The medical records show the doctor prescribed Sildenafil 25 milligram tablets to treat pulmonary hypertension associated with chronic obstructive pulmonary disease. 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.A physician reviewed the appeal and determined that the plan is not required to cover Sildenafil 25 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Shingrix 50 microgram/0.5 milliliter injection 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.Shingrix is a biologic on Tier 4 of the plans formulary. There are no 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 Lynparza 100 milligram tablets prescribed for extensive stage small cell lung 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 Lynparza for extensive stage small cell lung 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 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: Unfavorable

At issue is Losartan Potassium 100 milligram tablets 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.This drug is included on Tier 1 of the plans formulary. There are no cost-sharing tiers lower than Tier 1; therefore, a tier exception cannot be considered.  A physician reviewed your 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 Suprep 17.5-3.13 gram solution prescribed for preparation of bowel for procedure 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 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. 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 Suprep.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Oxycodone-Acetaminophen 10/325-milligram to chronic bilateral low back pain without sciatica. 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.Oxycodone-Acetaminophen is a generic drug on Tier 3 of the plans formulary. The prescriber has not indicated if all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Benzonatate 200 milligram capsule prescribed for cough relief. The 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 Benzonatate because drugs used for the symptomatic relief of cough and cold are excluded from coverage under Medicare Part D. If you purchased drugs/products that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug/product. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hizentra 10 gram/50 milliliter solution prescribed for use with an infusion pump for the treatment of primary immune deficiency 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. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows Hizentra is being administered to the enrollee via external infusion pump that is used in the home. According to Medicare rules, Medicare Part B pays for the rental and purchase of durable medical equipment, if the equipment used in the patients home. Payment may be made for supplies necessary for the effective use of DME, including drugs and biologicals, which must be put directly into the equipment to achieve the therapeutic benefit of the durable medical equipment. We determined that the Medicare Part D plan is not required to cover Hizentra. 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. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tribenzor 40-10-25 milligram tablet prescribed for hypertension. 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 prescriber's statement 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 Tribenzor.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Metanx RX capsule 314/35/2 milligram 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. The Food and Drug Administration indicates Metanx is listed as a vitamin/mineral. Therefore, we determined that the plan is not required to cover the Metanx or provide reimbursement. 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 Xywav 500-milligrams/milliliter Solution to treat idiopathic hypersomnia and hypersomnia with longstanding obstructive sleep apnea. 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 use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan tablet 550 milligram prescribed for 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 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 Acthar 80 units/milliliter gel vial prescribed for maintenance therapy for relapsing/remitting 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 indicates the prescriber ordered Acthar for maintenance therapy for relapsing/remitting multiple sclerosis. 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 Tadalafil 5 milligram tablet prescribed daily for benign prostatic hyperplasia and erectile dysfunction. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we reviewed the appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available. We have made 2 or more attempts to request a case file from the plan.The doctor prescribed Tadalafil 5 milligram tablet to treat the enrollees benign prostatic hyperplasia and erectile dysfunction. 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 Tadalafil 5 milligram tablet. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Viberzi 75 milligram tablet prescribed for an unknown diagnosis. The Part D plan denied your request because the drug was not included 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. 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 did not receive the documentation requested. Without a diagnosis it cannot be established that the Viberzi is being prescribed for a medically accepted indication. As such, Viberzi does not satisfy the definition of a Medicare Part D drug. The requested drug is not eligible for coverage under Medicare Part D. Therefore, an exception to the plans formulary will not be addressed.A physician reviewed your appeal and determined that the plan is not required to cover Viberzi.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metformin ER gastric 1000 milligram tablet prescribed daily 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. 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. A physician reviewed the appeal and determined that the plan is not required to cover Metformin ER gastric 1000 milligram tablet.