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

You asked the Plan to cover Simponi. The Plan did not grant this request. We received this case to conductan independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Simponi 50 mg/0.5 mL. The drug is requested to treat L73.2 Hidradenitis suppurativa and L88Pyoderma gangrenosum, which is an off-label (non-FDA approved) use. Medical records were providedwhich support these diagnoses. The Medicare-approved compendia do not contain any citations to supportthe use of the requested drug, as prescribed, for treatment of the noted condition. Therefore, the requesteddrug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, anexceptions request based on medical necessity cannot be considered because the requested drug, asprescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is noteligible for coverage under Medicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically acceptedindication. A medically accepted indication means a use that is approved by the FDA or a use that issupported by one or more citations in Medicare approved compendia.Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicareapproved compendia that support the use of Simponi for the diagnosed condition. As a result, the drug isnot being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot becovered under the Medicare Part D benefit for this condition. An exceptions request based on medicalnecessity cannot be considered because this drug, as prescribed, does not meet the definition of a MedicarePart D drug. Therefore, our decision is that the Plan is not required to provide coverage for Simponi.This decision does not concern the medical necessity of the requested drug. It only establishes if paymentcan be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for Nitrofurantoin Mono-Macro 100 mg purchased January29, 2019. The Plan did not grant this request. We received this case to conduct an independent review.Medicare rules state that an individual that meets requirements under Medicare's low income subsidy (LIS)rules is entitled to a reduction or elimination in the premium, a reduction or elimination in the annualdeductible, a reduction in cost-sharing for all covered Part D drugs below the out-of-pocket limit, and areduction or elimination in cost-sharing for covered Part D drugs above the out-of-pocket limit. The extentof reduction in these benefits depends on an individual's income and resources. According to enrollmentrecords from CMS, you were determined to be entitled to an LIS copay level 2, effective January 1, 2019through December 31, 2019. For copay level 2, an enrollee is required to pay $1.25 and $3.80 copayments.In this case, the Plan provided documentation that Nitrofurantoin Mono-Macro 100 mg was purchased onJanuary 29, 2019 for $3.80. The record shows that Nitrofurantoin Mono-Macro 100 mg was purchased foran amount that is less than or equal to the required LIS copayment amount.The case record indicates that the Plan provided coverage in accordance with the Part D Plan contract andwith the LIS benefit to which you were entitled. Therefore, our decision is the Plan is not required toprovide reimbursement for Nitrofurantoin Mono-Macro 100 mg purchased January 29, 2019.Please note: this decision only addresses Nitrofurantoin Mono-Macro 100 mg purchased January 29, 2019due to the Plan only forwarding the January 29, 2019 date of service for Nitrofurantoin Mono-Macro. Ifyou would like to dispute other dates of service for Nitrofurantoin Mono-Macro you may wish to contactthe Plan. There are other drugs that are being reviewed under different appeals. You will receive differentletters for each drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide a tiering exception for Repatha Pushtronex. The Plan did not grant thisrequest. We received this case to conduct an independent review.Medicare law and Plan rules do not allow tiering exceptions for non-formulary drugs being coveredthrough a formulary exception. The documentation in the record shows that Repatha Pushtronex iscurrently being covered for the enrollee through a formulary exception. Therefore, our decision is the Planis not required to provide a tiering exception for Repatha Pushtronex.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Tacrolimus 0.1% Ointment. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Tacrolimus 0.1% Ointment. The drug is requested to treat Zoon's plasma cell balanitis, which is an off-label (non-FDA approved) use. 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. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. 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.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. A medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia. Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicare approved compendia that support the use of Tacrolimus 0.1% Ointment for the diagnosed condition. As a result, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be covered under the Medicare Part D benefit for this condition. An exceptions request based on medical necessity cannot be considered because this drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage for Tacrolimus 0.1% Ointment. This decision does not concern the medical necessity 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 asked the Plan to cover Budesonide ER 9 mg. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Budesonide ER 9 mg. The drug is requested to treat gastroenteritis and unspecified colitis, which are off-label (non-FDA approved) uses. The Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted conditions. Therefore, the requested drug is not being prescribed for a medically accepted indication as defined by Medicare law. 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.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically accepted indication. A medically accepted indication means a use that is approved by the FDA or a use that is supported by one or more citations in Medicare approved compendia. Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicare approved compendia that support the use of Budesonide ER for the diagnosed condition. As a result, the drug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, it cannot be covered under the Medicare Part D benefit for this condition. An exceptions request based on medical necessity cannot be considered because this drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage for Budesonide ER. This decision does not concern the medical necessity 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 asked the Plan to cover Betamethasone Dipropionate. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Betamethasone Dipropionate 0.05% cream (360g/30days). The drug is requested to treat psoriasis. The Plan limits the amount of Betamethasone Dipropionate 0.05% cream to 135g/30days. Additional medical information was requested by the Part D QIC. The prescribing physician was asked to address the quantity limit. The prescriber statement was not returned. 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 enrollee's condition and/or would likely cause harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is not supported. Our Physician Reviewer's opinion is that quantity limit exception criteria are not met.Medicare rules allow a Part D Plan to manage its formulary by covering a limited quantity of certain drugs. A Plan must grant an exception if it determines that the requested dosage is medically reasonable and necessary, consistent with the prescriber's statement. Based on a review of the available documentation, our Physician Reviewer's opinion is that an exception to the quantity limit criteria is not met. Therefore, the Plan is not required to cover the requested quantity of Betamethasone Dipropionate.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Micardis. The Plan did not grant this request. We received this case to conductan independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Micardis. The drug is requested to treat essential hypertension. The prescriber has not indicated why allalternatives required by the Plan (Candesartan, Irbesartan, Losartan, Olmesartan, and Valsartan) wouldlikely not be as effective for the enrollee as the requested drug; and/or would likely cause adversereaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is notsupported. Our Physician Reviewer's opinion is that formulary exception criteria are not met.A Plan must grant an exception for a drug that is not on its formulary if it determines that the requesteddrug is medically necessary, consistent with the prescriber's statement. Based on a review of the availabledocumentation, our Physician Reviewer's opinion is that formulary exception criteria are not met.Therefore, the Plan is not required to cover Micardis.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to provide tiering exceptions for Eliquis and Jardiance. The Plan did not grant this request. We received this case to conduct an independent review.Medicare rules do not require the Part D plan to grant a tiering exception for a brand or biologic drug of the same type (such as brand or biologic drugs when considering an exception for a brand or biologic drug) if the lower tier(s) on the formulary only contain(s) generic alternative drugs. Eliquis and Jardiance are Tier 3 brand drugs. The lower cost-sharing tier(s) only contain(s) generic alternative drugs. Therefore, our decision is the Plan is not required to provide a tiering exception for Eliquis or Jardiance.
Appeal type: Prescription Drug
Decision: Favorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to cover SF. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for SF 1.1% topical dental gel (51gm/1 tube). The drug is requested for ongoing treatment of dental hypersensitivity and for prevention of root caries on exposed dentin (since 2011). Additional medical information was requested by the Part D QIC. The prescribing physician was asked to address formulary alternatives. The prescriber statement was returned. The prescriber stated that there is no alternate drug on your formulary. The prescriber has indicated why all alternatives required by the Plan would likely not be as effective as the requested drug for the enrollee, and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, an exception to the Plan's coverage criteria is medically necessary. Our Physician Reviewer's opinion is that formulary exception criteria are met.A Plan must grant an exception for a drug that is not on its formulary if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on a review of the available documentation, our Physician Reviewer's opinion is that formulary exception criteria are met. Therefore, the Plan is required to cover SF.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Cyclobenzaprine. The Plan did not grant this request. We received this case toconduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Cyclobenzaprine 10 mg. The drug is requested to treat chronic muscle spasms, which is an off-label(non-FDA approved) use. You stated that the expected length of therapy is one year and you are requestingthat the drug be dispensed as 60 tablets per 30 days. The Medicare-approved compendia do not contain anycitations to support the use of the requested drug, as prescribed, for treatment of the noted condition.Therefore, the requested drug is not being prescribed for a medically accepted indication as defined byMedicare law. As such, an exceptions request based on medical necessity cannot be considered because therequested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, therequested drug is not eligible for coverage under Medicare Part D for the noted condition.For coverage under Part D, Medicare requires that the drug must be prescribed for a medically acceptedindication. A medically accepted indication means a use that is approved by the FDA or a use that issupported by one or more citations in Medicare approved compendia.Our Physician Reviewer reviewed this file and determined that there are no citations in the Medicareapproved compendia that support the use of Cyclobenzaprine for the diagnosed condition. As a result, thedrug is not being prescribed for a medically accepted indication as defined by Medicare law. As such, itcannot be covered under the Medicare Part D benefit for this condition. An exceptions request based onmedical necessity cannot be considered because this drug, as prescribed, does not meet the definition of aMedicare Part D drug. Therefore, our decision is that the Plan is not required to provide coverage forCyclobenzaprine.This decision does not concern the medical necessity of the requested drug. It only establishes if paymentcan be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked the Plan to cover Oxycodone HCL ER. The Plan did not grant this request. We received thiscase to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the requestfor Oxycodone HCL ER. The drug is requested to treat chronic pain in an enrollee with malignantneoplasm of left lung. Oxycodone HCL ER is not on the Plan's formulary. Xtampza ER and Fentanyl patchare on the Plan's formulary. The prescriber has not indicated why all alternatives required by the Planwould likely not be as effective for you as the requested drug; and/or would likely cause adverse reaction(s)or other harm to you. Therefore, an exception to the Plan's coverage criteria is not supported. Our PhysicianReviewer's opinion is that formulary exception criteria are not met.A Plan must grant an exception for a drug that is not on its formulary if it determines that the requesteddrug is medically necessary, consistent with the prescriber's statement. Based on a review of the availabledocumentation, our Physician Reviewer's opinion is that formulary exception criteria are not met.Therefore, the Plan is not required to cover Oxycodone HCL ER.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for Mupirocin 2% Ointment purchased January 11, 2018 and September 19, 2018. The Plan did not grant this request. We received this case to conduct an independent review.Medicare rules state that an individual that meets requirements under Medicare's low income subsidy (LIS) rules is entitled to a reduction or elimination in the premium, a reduction or elimination in the annual deductible, a reduction in cost-sharing for all covered Part D drugs below the out-of-pocket limit, and a reduction or elimination in cost-sharing for covered Part D drugs above the out-of-pocket limit. The extent of reduction in these benefits depends on an individual's income and resources. According to enrollment records from CMS, you were determined to be entitled to an LIS, copay level 2, effective January 1, 2018 through December 31, 2018. For copay level 2, an enrollee is required to pay $1.25 and $3.70 copayment amounts.In this case, the Plan provided documentation that Mupirocin 2% Ointment was purchased January 11, 2018 and September 19, 2018 for $1.25 and $0. The record shows that Mupirocin 2% Ointment was purchased for an amount that is less than or equal to the required LIS copayment amount.The case record indicates that the Plan provided coverage in accordance with the Part D Plan contract and with the LIS benefit to which you were entitled. Therefore, our decision is the Plan is not required to provide reimbursement for Mupirocin 2% Ointment purchased January 11, 2018 and September 19, 2018.Please note: this decision only addresses Mupirocin 2% Ointment received January 11, 2018 and September 19, 2018 due to the Plan only forwarding the January 11, 2018 and September 19, 2018 dates of service for Mupirocin 2% Ointment. If you would like to dispute other dates of service for Mupirocin 2% Ointment you may wish to contact the Plan. There are other drugs that are being reviewed under different appeals. You will receive different letters for each drug.
Appeal type: Prescription Drug
Decision: Partially Favorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe.If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to usas required by Medicare rules because it did not make a timely decision.You asked the Plan to provide reimbursement for Tylenol (Acetaminophen) 325 mg, Aspirin EC 81 mg,Novolin N 100 unit/mL and Novolog 100 unit/mL received July 16, 2019 and July 17, 2019. The Plan didnot grant this request. We received this case to conduct an independent review.Novolin N and NovologThe Plan covers prescriptions filled at an out-of-network pharmacy only in certain limited circumstances.In this case, you were in the hospital in January 2019. You received several self-administered drugs duringthis stay. Reimbursement was requested from the Part D Plan. The Plan did not approve the request forNovolin N and Novolog on the basis that the amount administered was more than the quantity allowedaccording to the Plan's 2019 Formulary. Because you were outpatient at the hospital when you receivedthese drugs, you were not in a position to obtain the drugs that had been previously filled at a networkpharmacy, nor were they able to obtain prior authorization or off-formulary exception review. Since thiswas a one-time emergency stay, the Plan should provide an exception to their normal coverage rules. ThePlan's out-of-network coverage rules were followed. Therefore, our decision is the Plan is required toprovide coverage and reimbursement for Novolin N 100 unit/mL and Novolog 100 unit/mL received July16, 2019 and July 17, 2019.Tylenol (Acetaminophen) and Aspirin ECMedicare Part D does not cover non-prescription drugs. We checked FDA approved sources for the drugs'classification or determined from other available resources that the drugs are a non-prescription or OTCdrugs. Therefore, Tylenol (Acetaminophen) 325 mg and Aspirin EC 81 mg received July 16, 2019 and July17, 2019 are not eligible for Part D coverage, and the Plan is not required to cover or providereimbursement for them under the Part D benefit.This decision does not address the medical necessity or appropriateness of the requested drug. It onlyestablishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

Medicare rules require a Part D Plan to issue a decision regarding coverage within the specified timeframe. If the Plan does not make a timely decision, this is considered a denial. The Plan forwarded this case to us as required by Medicare rules because it did not make a timely decision.You asked the Plan to cover Xiidra. The Plan did not grant this request. We received this case to conduct an independent review.We asked a Physician Reviewer to determine whether the Plan was correct in denying the request for Xiidra which is subject to prior approval. Our Physician Reviewer needed additional information from the prescriber to make this determination. The prescriber was asked to address whether the drugs offered by the Plan for the treatment of the enrollee's condition would: (1) not be as effective as the requested drug; and/or (2) have adverse effects. The requested information was not received. Based on a review of the available documentation, neither prior authorization criteria nor prior authorization exception criteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. A Plan must grant an exception to prior approval rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. Based on the available documentation, our Physician Reviewer's opinion is that an exception to prior approval criteria is not met. Therefore, the Plan is not required to cover Xiidra.