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

The enrollee requested Aspirin low dose 81 milligram 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.We determined that the plan is not required to cover Aspirin because it is considered an over-the-counter drug and is excluded from coverage under Part D. Your plan does not indicate that you are eligible for supplemental (additional) coverage for the Aspirin. 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

The enrollee requested Lisinopril 40 milligram tablets prescribed daily 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. The plan submitted documentation that shows the enrollee was in the initial coverage stage of the Part D benefit when this drug was purchased. According to the plans Evidence of Coverage, Lisinopril is a tier 1 drug with a copay of $9, in the initial coverage stage. The record shows the full price of the drug was less than the $9 copay amount. Therefore, the charge was based on the total cost of the drug. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Dulera Hydrofluoroalkane (HFA) 100-5 microgram inhaler prescribed to treat asthma. 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.The documentation satisfies the plans coverage criteria. The prescriber states the requested medication is for the treatment of asthma. Medical records were provided from date of service 7/8/2021 which substantiate the diagnosis of asthma.  A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methocarbamol 750 milligram tablet prescribed for 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 records submitted at the reconsideration level. The prescriber indicates that they prescribed Methocarbamol for a recent back injury/strain and it is only for short term use. However, there was no documentation that the enrollee was using Methocarbamol as an adjunct to rest, therapy, or other relief measures and there is no attestation the prescriber was aware that the medication benefits outweigh the risk as required for enrollees at age 65 to 105 years old. Medicare approved compendia does not support the use of the drug for the reported condition.    A physician reviewed your appeal and determined that the plan is not required to cover Methocarbamol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dulera 200-5 microgram/ actuation aerosol. 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. Dulera 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram prescribed two times daily for paroxysmal atrial fibrillation. 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.Eliquis 5 milligram is a brand drug on Tier 2 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 Dextroamphetamine-Amphetamine extended release 20 milligram capsules prescribed for attention deficit hyperactivity disorder. 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. The prescriber indicates the enrollee is stable on this medication and tolerates the capsules better than the tablet form. In this case, the medical records do not support why all the 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 Dextroamphetamine-Amphetamine capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lorazepam 1 milligram tablet prescribed 40 tablets per 13 days for general anxiety disorder. 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. Your prescriber requested Lorazepam 1 milligram tablet at a quantity of 40 tablets per 13 days. However, the plan has a quantity limit of 90 tablets per 30 days. The documentation does not support a medical necessity for an exception to the plans quantity limit.  A physician reviewed your appeal and determined that the plan is not required to cover Lorazepam 1 milligram tablet with a quantity of 40 tablets per 13 days.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cefixime 400 milligram capsule prescribed for chronic prostatitis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any information submitted at the reconsideration level. The prescriber indicates Cefixime 400 milligram capsule is prescribed to treat chronic prostatitis. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Cefixime.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Auryxia 1 gram 210 milligrams (Iron) tablets prescribed to treat iron deficiency related to end-stage renal disease. 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.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 Auryxia 1 gram 210 milligrams (Iron) tablets. 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 Estradiol 0.025 milligram patch prescribed two times per week for symptomatic menopausal or female climacteric state. 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.We asked the prescriber to send us information about the enrollees condition. We also asked for medical records or other documentation to show why the medication was needed. Specifically, we asked for records to show why similar medications on the lower tiers would not work. We received the documentation and included it in our review.Estradiol 0.025 milligram patch is a generic drug on Tier 3 of the plans formulary. The prescriber statement and medical records did not address why the drugs available on the lower tiers of the plans formulary would not work for the enrollee. 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 a request for coverage of Forteo 620 microgram per 2.48 milliliter subcutaneous injection pen. 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. The documentation submitted to the plan indicates that Forteo has been prescribed for an enrollee who is paraplegic and has a history of an osteoporotic fracture. However, the Medicare approved compendia do not contain any citations to support the use of Forteo for this condition.During this review, a request was submitted to the prescriber to clarify the diagnosis, to address the plans prior authorization requirements for coverage of this this drug, and to provide supporting medical records. The prescriber did not respond to the request. Therefore, the available documentation does not support that the requested drug is being prescribed for a medically accepted indication. As such, the drug is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Drizalma Sprinkle DR 60 milligram delayed release capsules. The Part D plan denied the request because the drug was being prescribed for a non-medically accepted indication.  We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation initially submitted to the plan indicates that Drizalma Sprinkle DR was prescribed for the treatment of dysphagia following cerebral infarction. However, the Medicare approved compendia do not contain any citations to support the use of Drizalma Sprinkle DR for the treatment of dysphagia following cerebral infarction.During this review, a request was submitted to the prescriber to clarify the diagnosis, to address the plans prior authorization requirements for coverage of this drug, and to provide supporting medical records and a prescriber statement of medical necessity. We received answers to questions on a form; however, no supporting medical records or prescriber statement of medical necessity was submitted. It is noted on the form that the enrollee is receiving Drizalma Sprinkle DR capsules for the treatment of major depressive disorder and generalized anxiety order. These are medically accepted indications for the use of Drizalma Sprinkle DR outlined in the Medicare approved compendia. However, the Part D plan has prior authorization requirements that have to be met before coverage of this drug is allowed. It is not possible to validate that the plans coverage criteria have been satisfied with the available documentation. 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 Lidocaine Topical Patch 5%.  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.On 6/27/2021 the prescriber was asked if the drug was being used to treat post-herpetic neuralgia.  The prescriber answered, 'No.'  Then on 7/30/2021 the prescriber submitted a form dated  10/10/2016 in which they stated that the drug was being used to treat post-herpetic neuralgia.  The prescriber was asked to submit medical records.  No medical records were submitted.  In order to establish medical necessity and confirm that the requested drug is being used for a medically accepted indication, as required by Medicare, medical records supporting that medically accepted indication are required. These records were requested from the prescriber, and we did not receive information that could answer these medical necessity issues.  A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine Topical Patch 5%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prolia 60-milligrams/milliliter Solution Prefilled Syringe Subcutaneous to treat unspecified osteoporosis, unspecified site. 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 record shows your physician prescriber ordered Prolia to treat your osteoporosis. We asked the prescriber to send us a prescriber statement, prior authorization documentation, laboratory reports, and medical records. We received some medical records, however the prescriber did not answer the questions we submitted.  The provided documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. 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 Temazepam 15 milligram capsules. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We requested additional documentation from the prescriber. Specifically, we requested medical records and a prescriber statement to support the enrollee met the plans prior authorization coverage criteria. However, no further information was received.The submitted documentation does not include medical records or evidence of a prescribed diagnosis. As it cannot be determined 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 Dual Compound Med 3 milliliter (60.00VL) prescribed for unknown diagnosis. We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows the enrollee requested the plan to provide reimbursement for Dual Compound Med. However, the plan indicates that there is missing information needed to consider the request. The documentation provided includes a statement from the compounding pharmacy. It does not include a breakdown of ingredients for the Dual Compound Med including the National Drug Code (NDC) for each of the ingredients. According to your plan's Evidence of Coverage, if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that the enrollee paid for the drug was not provided. In addition, the prescribers name and National Provider Identifier (NPI) number of the prescriber is missing. Therefore, we determined that the plan is not required to reimburse the enrollee without the required documentation.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Livalo 2 milligram tablets prescribed to treat 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.Upon redetermination, the Part D plan denied the appeal stating that the formulary exception request was not met. However, the documentation shows the doctor prescribed Livalo 2 milligram tablets to treat hypertension. According to DRUGDEX, a Medicare approved compendium, the medically accepted indication is hyperlipidemia for the use of Livalo. The documentation provided fail to support the diagnosis of hyperlipidemia.  Relevant medical records were requested but not provided. A physician reviewed the appeal and determined that the plan is not required to cover Livalo 2 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Piperacillin Sodium-Tazobactam Sodium intravenous solution 40.5 (36-45) gram prescribed for diverticulitis of colon (without mention of hemorrhage) and diverticulitis of large intestine with perforation and abscess without bleeding. 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 Piperacillin Sodium-Tazobactam Sodium was prescribed to be administered by intravenous infusion pump in the home to treat diverticulitis of colon (without mention of hemorrhage) and diverticulitis of large intestine with perforation and abscess without bleeding. Based on the information provided, we determined the drug may be eligible for coverage under Part B under Medicare rules.  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 Fluorouracil cream 5%. 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. Fluorouracil cream 5% 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 5 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.Eliquis 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 Nurtec 75 milligrams oral disintegrating tablets prescribed to treat migraines. 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 prescriber indicates that one of plans alternative formulary drug was tried and failed or could cause harm. In order to grant an exception for a drug not on the plans formulary, all alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the records do not support why all other drugs on the plans formulary would not work for the enrollee.A physician reviewed the appeal and determined that the plan is not required to cover Nurtec 75 milligrams oral disintegrating tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Apokyn 225 milliliter per 30 days. 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 4 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 Tacrolimus 0.1% ointment prescribed to treat seborrheic dermatitis. 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 documentation shows the doctor prescribed Tacrolimus 0.1% ointment to treat seborrheic dermatitis. However, the Medicare approved compendia do not 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 Tacrolimus 0.1% ointment.