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

At issue is Hetlioz 20 milligram capsule prescribed for non-24 hour sleep-wake disorder. 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 the prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.The medical records show the doctor prescribed Hetlioz 20 milligram tablet to treat non-24- hour sleep-wake disorder. The enrollees 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 Hetlioz. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Bystolic 10 milligram tablets prescribed 1 a day for hypertension with a quantity requested of 90 tablets. 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. Your prescriber indicates that Bystolic 10 milligram tablets to be taken 1 tablet a day with a quantity of 90 tablets is requested to treat your hypertension. However, the drug is a Tier 4 non-preferred drug and drugs in this Tier are limited to up to a 30 day supply. We determined that the plan is not required to cover a 90 day supply of Bystolic 10 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Zolpidem Tartrate 12.5 milligram extended release 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.The submitted documentation contains a prescriber statement; however, no medical records were submitted for review. A request for information was sent to the prescriber; however, no further documentation was received. The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed, with support of medical records, the issues regarding this high-risk medication, and why alternative safer medications, in the plan's formulary, could not be used. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverageA 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 Stelara 90 milligram subcutaneous prescribed every 8 weeks for ulcerative colitis 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 medical records support the gastroenterologist prescribed Stelara to treat the enrollees ulcerative colitis. 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 support the enrollee has satisfied the plan's coverage criteria.A physician reviewed the appeal and determined that the plan is not required to cover Stelara 90 milligrams. The medical records do not support the enrollee has had an initial loading dose of Stelara 390 milligram intravenously. The prescriber's office was also contacted by phone, there was no record of an induction dose provided. 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 a request for Euflexxa 20 milligram/2 milliliter prefilled syringe prescribed twice monthly for osteoarthritis of the knee. The Part D plan denied the request.We performed and 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 determined that the plan is not required to cover Euflexxa because it is considered a medical device. Medical devices are excluded from coverage from Medicare Part D. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, they must pay for them themselves. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Shingrix 50 microgram/0.5 milliliter injection prescribed for shingles vaccination. The Part D plan denied the enrollees request.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 the Shingrix vaccine and administration fee. However, Medicare records indicate that the enrollee was not enrolled with the Part D plan for the date of service requested. Therefore, we determined that the plan is not required to reimburse the enrollee for the Shingrix vaccine and administration fee.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Austedo 12 milligram oral tablet prescribed daily for tardive dyskinesia. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. We received some documentation and included it in our review.You requested Austedo 12 milligram oral tablet for the treatment of tardive dyskinesia. However, no medical records have been submitted for review. Therefore, it cannot be determined if the requested drug was prescribed for a medically accepted indication supported by the Medicare approved compendia. As such, the formulary exception was not addressed because 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 cover Austedo.
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.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 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 does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed, with support of medical records, the issues regarding this high-risk medication, and why alternative safer medications, in the plan's formulary, could not be used. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverageA 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 Dronabinol 10 milligram capsules prescribed as an appetite stimulant. 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 determined that the plan is not required to cover Dronabinol because it was prescribed for weight gain. Drugs to treat anorexia, weight loss, or weight gain are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Ozempic 2 milligram/1.5 milliliter dose pen prescribed for the enrollees condition. The Part D plan denied your 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.Ozempic 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 Zolpidem Tartrate 10 milligram tablets prescribed for an unknown diagnosis. The Part D plan denied your request because prior authorization requirements were not met. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the medication is needed. We did not receive the documentation requested.Without medical records we cannot determine that the drug is being prescribed for a medically accepted indication. As such, Zolpidem Tartrate 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 cover Zolpidem Tartrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Savaysa 60 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.The submitted documentation contains a prescriber statement; however, no medical records were submitted for review. A request for information was sent to the prescriber; however, no further documentation was received. This medication is not on your plan's list of medications. The prescriber has not given a clear medical reason why all medications required by the plan on that list did not work for you. This reason has to be in the medical record with details of when you tried those medications. The reason the medications on the formulary won't work or could cause you harm have to be stated. Why the other medications required by the plan will not work must be discussed. Therefore, an exception to the plans formulary coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.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 Cortef 5 milligram tablet prescribed for congenital adrenal hyperplasia due to 21-hydroxylase deficiency, chronic. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The prescriber indicates they prescribed Cortef 5 milligram tablet to treat congenital adrenal hyperplasia due to 21-hydroxylase deficiency, chronic. 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 all 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 Cortef.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Floricet prescribed for headaches.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. 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.  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 cover Floricet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Prolia 60 milligram/milliliter syringe prescribed for the enrollees condition. The Part D plan denied your 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.Prolia is a biologic on Tier 4 of the plans formulary. There are no biologics of the same type on the lower cost sharing tiers. Therefore, this biologic is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Epclusa 400 milligram/100 milligram tablets prescribed for chronic hepatitis C virus, unknown genotype. 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 asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. We did not receive the documentation requested. The submitted documentation indicates the prescriber ordered Epclusa for chronic hepatitis C virus, unknown genotype. 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. Additionally, the plan's prior authorization requirements are not satisfied by the provided information, and quantity limits are exceeded by the request.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 Gammaked Solution 5 gram/50 milliliter prescribed for glutamic acid decarboxylase antibodies associated cerebellar ataxia. 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. Your prescriber indicates that Gammaked Solution is prescribed for glutamic acid decarboxylase antibodies associated cerebellar ataxia. 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 Gammaked Solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Lantus Solostar 100 units/milliliter injection prescribed for the enrollees condition. 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.Lantus Solostar is a biologic on Tier 3 of the plans formulary. There are no biologics of the same type on the lower cost sharing tiers. Therefore, this biologic is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine Hydrochloride 2 milligram sublingual tablets prescribed for chronic pain syndrome. 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 medical records submitted support Buprenorphine Hydrochloride 2 milligram sublingual are prescribed for chronic pain syndrome. However, Medicare approved compendia do not support the use of this drug, in this form, for the enrollees condition.   A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine Hydrochloride sublingual tablets.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Budesonide ER 9 milligram extended-release tablets, 30 tablets per 30 days. The Part D plan denied the request for coverage because the drug was being prescribed for irritable bowel syndrome, which was not a medically accepted indication for the drug.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. During this review a prescriber statement of medical necessity and supporting medical records were requested from the prescriber. The prescriber responded and submitted the requested documentation.The newly submitted medical records, including biopsy results, confirm that Budesonide ER is being prescribed in the management of microscopic colitis, specifically collagenous colitis. The treatment of microscopic colitis is a medically accepted indication for the use of Budesonide ER, as outlined in the Medicare approved compendium, DrugDex. The medical records indicate that the enrollees microscopic colitis is currently causing significant symptoms with multiple loose stools and frequent episodes of accidental bowel leakage. The prescriber notes that Pepto-Bismol and Imodium have not been helpful and a course of daily Budesonide ER is recommended. The plans quantity limit for the drug is 30 tablets per 30 days, which is what has been prescribed. Therefore, the medical records validate that the medication is being prescribed for a medically accepted indication and the plans quantity limit requirements have not been exceeded. The plans prior authorization requirements for coverage of this medication are specifically related to having a diagnosis of mild to moderate active ulcerative colitis. Since the drug is being prescribed for a medically accepted indication and the medical records support the medical necessity for the drug, an exception to the plans diagnosis-specific prior authorization requirements will be granted. 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 coverage for Hetlioz 20 milligram capsules prescribed for the management of circadian rhythm sleep disorder free run type, non-24-hour sleep-wake disorder. 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 plan has prior authorization requirements that must be met before coverage of this medication will be approved. The prescriber has not provided any medical records to validate that the plans 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 Prednisone 1 milligram tablet(s). 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 also researched Medicare systems and reviewed the enrollment data available.We asked the prescriber to send us information regarding the enrollees condition(s). We also asked for medical records and other documentation to show why the medication is needed. We did not receive the documentation requested.The operative note supports that the enrollee had undergone a pancreas transplant on June 20, 2021, and is post kidney transplant status. The documentation shows Prednisone 1 milligram tablet(s) is being requested. However, this drug may be eligible for coverage under Medicare Part B. Medicare Part D cannot pay for drugs that are covered by Medicare Part B.We determined that the plan is not required to cover Prednisone 1 milligram tablet(s).