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

At issue is Evenity 105-milligrams/1.17-milliliter Solution Auto-Injector to treat osteoporosis, not postmenopausal. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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 Hydroquinone, Tretinoin, and Fluocinolone 30-gram Cream. The case was auto-forwarded by the plan.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.This drug is a compounded drug. Therefore, we reviewed each ingredient individually. The ingredients of the requested drug are Hydroquinone, Tretinoin, and Fluocinolone.Hydroquinone has not been found by the United States Food and Drug Administration to be safe and effective and the drug product labeling has not been approved by the Food and Drug Administration. Therefore, the Hydroquinone is not eligible for Part D coverage.Tretinoin and Fluocinolone are bulk powders. Bulk powders (i.e., Active Pharmaceutical Ingredients for compounding) do not satisfy the definition of a Part D drug and are not covered by Part D. Therefore, none of the ingredients of the requested drug are Part D drugs. Compounded medications that do not contain at least one ingredient that meets the definition of a Part D drug are excluded from coverage.Our physician reviewer has determined that the compounded Hydroquinone, Tretinoin, and Fluocinolone 30-gram Cream is excluded from coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram oral tablet. 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. 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 your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Favorable

You requested Oxycodone/Acetaminophen 5/325 tablets prescribed 1 to 1.5 tablet daily as needed for chronic back pain.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. Your medical records show your doctor prescribed Oxycodone /Acetaminophen to treat your chronic pain. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for your condition: Acetaminophen in combination with oxycodone is effective for the treatment of moderate to moderately severe pain. A physician reviewed your appeal and determined that the plan is required to cover Oxycodone /Acetaminophen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Belladonna-Opium 16.2-30-milligram Suppository. 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.Non-Food and Drug Administration approved drugs are excluded from Medicare Part D coverage. Per the compendia, This drug has not been found by the United States Food and Drug Administration to be safe and effective, and the drug product labeling has not been approved by the Food and Drug Administration. Therefore, the requested drug is excluded from coverage.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Orencia 125 milligram per milliliter syringe prescribed for rheumatoid arthritis. 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. We asked your 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 received the documentation and included it in our review.Your medical records show your doctor prescribed Orencia to treat your rheumatoid arthritis. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Orencia. The physician submitted a supporting statement and medical records that show the enrollee has had an inadequate response to Methotrexate, a disease-modifying antirheumatic drug. The physician reviewer also determined that an exception to the plans prior authorization requirements can be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jardiance 25 milligram tablets prescribed daily. 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. Jardiance 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 your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Docusate Sodium 250 milligram softgel prescribed daily for unknown diagnosis. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. A request was submitted to the prescriber to provide a diagnosis, to address the prior authorization criteria, and to provide supporting medical records.  A reply from the prescriber was not received.  Without a diagnosis, it cannot be established that the requested drug is being prescribed for a medically accepted indication.  As such, the requested drug does not satisfy the definition of a Medicare Part D drug.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.  A physician reviewed your appeal and determined that the plan is not required to reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Motegrity 2 milligram tablets to treat constipation, unspecified (K59.00), due to rectal dyssynergy. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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 coverage for Prevident 5000 1.1% Dry Mouth toothpaste. The Part D plan your request for coverage.  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.Prevident 5000 1.1% Dry Mouth toothpaste is not approved by the Food and Drug Administration for safety and effectiveness. Drugs not approved by the Food and Drug Administration are excluded from Part D coverage. Therefore, the Prevident 5000 1.1% Dry Mouth toothpaste is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Horizant 600 milligram tablets prescribed as directed for radiculopathy, lumbar region and unspecified mononeuropathy of bilateral lower limbs. 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 Horizant to treat your radiculopathy, lumbar region and unspecified mononeuropathy of bilateral lower limbs. 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 Horizant.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Skyrizi 150 milligram Dose Kit prescribed to treat psoriasis vulgaris. The Part D plan denied the request. We performed 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. Skyrizi was prescribed to treat psoriasis vulgaris. The drug is not on the plans formulary. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Skyrizi.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Shingrix vial kit. 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. Shingrix is a biologic drug on Tier 4 of the plans formulary. There are no biologic 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 Morphine Sulfate 60 milligram extended release tablet prescribed three time daily for chronic shoulder pain and post-polio syndrome. 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 asked your 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 received the documentation and included it in our review.Your records show your doctor prescribed Morphine Sulfate to treat your chronic shoulder pain and post-polio syndrome. 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 your appeal and determined that the plan is not required to cover Morphine Sulfate. There is no documentation that supports non-opioid therapies have been optimized. 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 Oxycodone Hydrochloride 15 milligram tablets prescribed 60 tablets per 30 days to treat low back pain. The Part D plan denied the requested quantity of the medication.  We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The plan limits the amount of opioid the enrollee can have on hand.  The prescriber states that the requested morphine milligram equivalent on hand per day is 165 milligrams.  The quantity of Oxycodone 15 milligram tablets, 60 tablets per 30 days, would result in the enrollee having greater than 165 milligrams or more morphine equivalents on hand per day. Therefore, an exception to the plans coverage criteria is not supported.  Our physician reviewer's opinion is that quantity limit criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Albuterol Sulfate 2.5 milligram per 3 milliliter nebulizer solution prescribed for pneumonia. 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. The documentation indicates that the Albuterol Sulfate is being administered via nebulizer. Medicare rules state that Medicare Part B pays for the rental and purchase of durable medical equipment, such as a nebulizers, if the equipment is used in the patient's home or in an institution that is used as a home. 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. Additionally, the documentation indicates that the Albuterol Sulfate has been prescribed for pneumonia and/or acute bronchitis. 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 the Albuterol Sulfate nebulizer solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Megestrol Acetate 625 milligram per 5 milliliter oral solution. 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. The documentation indicates that Megestrol Acetate has been prescribed for decreased appetite with weight loss status post an allogeneic stem cell transplant due to the presence of chronic myelomonocytic leukemia. 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 the Megestrol Acetate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dalfampridine Extended Release 10 milligram tablets prescribed to treat walking in an enrollee with multiple sclerosis. 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. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. We requested additional information from your prescriber but did not receive a response. The prior authorization requirements were not met.A physician reviewed your appeal and determined that the plan is required to cover Dalfampridine Extended Release Tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Modafinil 200 milligram tablet prescribed for multiple sclerosis related fatigue. 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 Modafinil for multiple sclerosis related fatigue. 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 Modafinil.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Pregabalin 50-milligram capsules 90/30.  The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication.  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 prescribers office was contacted via phone, a registered nurse accessed the medical record and confirmed patient is a Type II diabetic having burning pain in the extremities. This is a medically accepted indication.The requested drug is eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Gabapentin 300 milligram capsules prescribed to treat diabetic neuropathy.  The Part D plan forwarded 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 prescriber submitted office notes which document diabetic neuropathy.  The documentation does not satisfy the plans coverage criteria.  Diabetic neuropathy is a non FDA approved, medically accepted indication.  Therefore, an exception to the plans coverage criteria is medically necessary. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Eliquis 5 milligram tablets prescribed for atrial fibrillation. 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. Eliquis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat your condition on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to cover the Eliquis at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Memantine Hydrochloride 10 milligram tablets. 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 Memantine Hydrochloride has been prescribed for anxiety and obsessive-compulsive disorder. However, the Medicare approved compendia do not contain any citations to support the use of Memantine Hydrochloride for the treatment of the noted conditions. While the plan has granted an exception and authorized coverage the Memantine Hydrochloride, a tiering exception will not be granted by the plan for a drug that is being used for a non-medically accepted indication. A physician reviewed the appeal and determined that the plan is not required to cover the Memantine Hydrochloride at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 10-milligram tablet to treat insomnia. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. This drug is considered a high-risk medication in older enrollees. 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 does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan, with supporting medical documentation, would likely cause harm or not be as effective as the requested drug.  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 Cialis 20 milligram tablets to treat erectile dysfunction. 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.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not Food and Drug Administration approved, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Spiriva Respimat 2.5 milligram inhaler. 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.Spiriva Respimat 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 your appeal and determined that the plan is not required to grant your request for a tiering exception.