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

At issue is Tretinoin 0.05% cream. 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 records submitted at the reconsideration level.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication was needed. We did not receive the documentation requested.The doctor prescribed Tretinoin 0.05% cream but stated the enrollee did not have the diagnosis of acne vulgaris. At reconsideration the enrollee states she does have a diagnosis of acne vulgaris. However, no medical records were provided by the prescriber to support this diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested 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 Tretinoin 0.05% cream.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem 12.5-milligram tablet to treat insomnia. 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. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported. 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 Nexletol 180-milligram tablet to treat hyperlipidemia, unspecified. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Nexletol to treat your hyperlipidemia, unspecified. The medical records also document a history of clinical atherosclerotic cardiovascular disease.  Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 10 milligram tablet prescribed daily for insomnia. 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 records submitted at the reconsideration level.The doctor prescribed Zolpidem Tartrate to treat the enrollees insomnia. 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 Zolpidem Tartrate. 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 Granisetron Hydrochloride 1-milligram tablet to treat prevention of nausea and vomiting due to Crohns 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 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

You requested Xifaxan 550 milligram tablet prescribed as directed for other specified bacterial intestinal infections and constipation, unspecified. 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 Xifaxan to treat your other specified bacterial intestinal infections and constipation, unspecified. However, the Medicare approved compendia do not support the use of this drug for your 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 a request for coverage of Testosterone 1.62% gel pump prescribed for male hypogonadism. The Part D plan denied the request for coverage.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. Testosterone 1.62% gel pump is not included in the plans formulary (list of covered drugs). The prescriber has not provided sufficient clinical rationale, supported by medical records, as to why the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue a request for coverage of Ipratropium Bromide-Albuterol Sulfate 0.5-3 milligram per 3 milliliter nebulizer ampules prescribed for the treatment of chronic obstructive pulmonary 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 documentation indicates that the Ipratropium Bromide-Albuterol Sulfate is going to be used with a nebulizer in the enrollees home. Medicare rules state that Medicare Part B pays for the rental and purchase of durable medical equipment, such as a nebulizers. Payment will also be made under Medicare Part B for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals, which must be put directly into the equipment to achieve the therapeutic benefit of the durable medical equipment. Coverage under Part D is excluded for any drug for which payment would be available under Part B. We have determined that the Medicare Part D plan is not required to cover the requested drug. 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. Please submit the request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Esbriet 267 milligram tablets. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We requested additional documentation related to this case. Specifically, we asked the prescriber to submit medical records to support a covered diagnosis and a prescriber statement. However, we did not receive the requested information.The submitted documentation does not contain 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 compounded drug Lidocaine/Nystatin/M-Dryl for unknown diagnosis. The Part D plan approved the Lidocaine and Nystatin ingredients. However, the M-Dryl ingredient was denied.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 Lidocaine and Nystatin ingredients are not addressed in this decision. According to Medicare rules, over-the-counter drugs are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover the M-Dryl. The plans Evidence of Coverage indicates that the supplemental benefit permits coverage for certain approved over-the-counter drugs/products, but only when ordered online by mail order. 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 Cevimeline Hydrochloride 30 milligram capsules prescribed for Sjogrens syndrome related xerostomia. 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 your 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 the appeal and determined that the plan is not required to cover Cevimeline Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is  Lidocaine-Prilocaine 2.5%-2.5% cream prescribed for chronic left shoulder pain.  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 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil Citrate 20 milligram tablets prescribed for pulmonary hypertension, likely World Health Organization group 2. 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 related to this case. Specifically, we asked the prescriber to submit medical records to support a covered diagnosis and a prescriber statement. However, we did not receive the requested information.The submitted documentation dated 7/7/2021 indicates the prescriber ordered Sildenafil Citrate for pulmonary hypertension, 'likely World Health Organization group 2.'  The prescriber indicated on appeal that the enrollee was considered to possibly have pulmonary hypertension, World Health Organization group 1. However, the medical records do not support this diagnosis. 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 Muse Pellets 1000 microgram prescribed for male erectile dysfunction. 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 only approved use in adults for Muse Pellets, per Medicare approved compendia, is erectile dysfunction. Drugs used to treat sexual or erectile dysfunction are excluded from Medicare Part D drug benefits. A physician reviewed your appeal and determined that the plan is not required to cover Muse Pellets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil Citrate 20 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.Sildenafil Citrate is a generic drug on Tier 3 of the plans formulary. There are no 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 a prior authorization request for Hetlioz 20 milligram capsules prescribed for circadian rhythm sleep disorder, free run type. The Part D plan denied coverage.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We requested additional documentation related to this case. Specifically, we asked the prescriber to submit medical records to support a covered diagnosis and a prescriber statement. However, we did not receive the requested information.The documentation on hand does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Dexcom G6 Sensor prescribed for diabetes, type 1. 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 Lidocaine 5% patch prescribed for joint 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.We requested additional documentation related to this case. Specifically, we asked the prescriber to submit medical records to support a covered diagnosis and a prescriber statement. However, we did not receive the requested information.The submitted documentation indicates the prescriber ordered Lidocaine for joint pain. 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 Lidocaine 5% patch prescribed for chronic low back pain due to osteoarthritis. 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 related to this case. Specifically, we asked the prescriber to submit medical records to support a covered diagnosis and a prescriber statement to clarify the medical history. However, we did not receive the requested information.The submitted documentation indicates the prescriber ordered Lidocaine 5% patch for chronic low back pain due to osteoarthritis. 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 Eliquis 5 milligram tablets. 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.Eliquis is provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are 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 Prednisolone PO4/Bromide OPH Solution 1% 0.075% 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 Prednisolone PO4/Bromide OPH Solution or provide reimbursement. According to Medicare rules, drugs that fall into the category of bulk powders do not meet the definition of a Part D drug. The Prednisolone PO4/Bromide OPH Solution is consistent of bulk powder ingredients 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

At issue is a request for coverage of Zolpidem Tartrate 5 milligram tablets prescribed for insomnia. The Part D plan denied the request for coverage.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 has prior authorization requirements that must be met before coverage of this medication will be approved. The submitted documentation does not include any medical records to validate that the plans coverage criteria have been satisfied. 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 Ambrisentan 10 milligram tablets prescribed to treat chronic thromboembolic 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.We asked the prescriber to send us information regarding your condition. We asked for medical records or other documentation to show why the enrollee needs this medication. We did not receive the requested documentation.The appeal request is for Ambrisentan 10 milligram tablets to treat chronic thromboembolic pulmonary hypertension, pulmonary hypertension WHO group 4. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the plan is not required to cover Ambrisentan 10 milligram tablets.