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

At issue is Botox 200 unit vial prescribed in preparation for a complex hernia repair to decrease post-operative risks. 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 prescriber indicates that Botox is prescribed for abdominal wall injections in preparation for a complex hernia repair. 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 Botox.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Toujeo Solostar 300 units per milliliter solution pen-injector. 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.Toujeo Solostar 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 your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligram tablet prescribed for irritable bowel syndrome with constipation. 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 prescriber indicates that Xifaxan is prescribed for irritable bowel syndrome with diarrhea. The documentation in the case file indicates the drug is requested for irritable bowel syndrome with constipation. The documentation is conflicting as too what the diagnosis was and we were unable to confirm the diagnosis with the prescriber. In order to establish medical necessity and confirm that the requested drug is being used for a medically accepted indication, as required by Medicare, documentation supporting that medically accepted indication are required. 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 Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rexulti 1 milligram tablet prescribed daily for major depressive 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 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 received the documentation and included it in our review.The medical records show the doctor prescribed Rexulti to treat the enrollees major depressive disorder. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The medical records provided do not support the prescriber statement and do 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 Rexulti. 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 Cyclobenzaprine HCL 10 milligram tablet prescribed for headache. 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 shows Cyclobenzaprine HCL prescribed to treat headache. However, the Medicare approved compendia do not support the use of this drug for the enrollees conditions. A physician reviewed your appeal and determined that the plan is not required to cover Cyclobenzaprine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Fasenra 30 milligram/milliliter auto injector prescribed for severe persistent asthma. 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 records submitted at the reconsideration level. The documentation on hand does not include medical records or a prescriber supporting statement. A request for information was sent to the prescriber; however, no further documentation was received. The documentation submitted does not support the enrollee satisfies the plans prior authorization coverage criteria. A physician reviewed the appeal and determined that the Fasenra is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a prior authorization request for Viberzi 75 milligram tablets prescribed for irritable bowel syndrome with diarrhea. 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. The enrollee satisfies the plan's coverage criteria. The prescriber submitted a statement and medical records to support the enrollee was prescribed Viberzi for irritable bowel syndrome with diarrhea. The documentation supports the enrollee has had previous treatment with Dicyclomine and Loperamide.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 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 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 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 Megestrol Acetate 40-milligrams/milliliter Solution to treat anorexia. 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.Drugs prescribed to treat anorexia and/or weight loss, unrelated to Acquired Immune Deficiency Syndrome wasting or cachexia due to certain chronic diseases, 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 Hetlioz 20 milligram capsule prescribed daily for non 24-hour sleep/wake 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 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 received the documentation and included it in our review.Hetlioz was prescribed to treat the enrollees non 24-hour sleep/wake disorder. 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 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

The enrollee requested Atenolol 25 milligram tablets prescribed for unknown diagnosis. 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 record shows the enrollee receives Atenolol from a mail order network pharmacy. The plans 2020 Evidence of Coverage indicates the copay for a mail-order pharmacy is $5 for a 1-100 day supply. When there is a shortage of a drug in the marketplace and the amount of available supplies, a reduction in the quantity is dispensed and one cost share is charged, per fill. In this case, the enrollee received two separate mail orders of a 30 day supply of Atenolol and was charged $5 copay for each. We determined that the plan was correct in its calculation of each copay and therefore, is not required to provide additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Morphine Sulfate 30-milligram Extended Release tablet to treat an unknown condition. 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 plan limits the amount of Morphine Sulfate provided to a 30-day supply. 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: Favorable

At issue is Octreotide 1000 micrograms per milliliter prescribed 500 micrograms three times daily for esthesioneuroblastoma and leptomeningeal 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 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 documentation shows the doctor prescribed Octreotide to treat the enrollees esthesioneuroblastoma and leptomeningeal disease. Olfactory neuroblastoma is on the spectrum of neuroendocrine tumors and SSTK2A is a neuroendocrine marker. Micromedex, a Medicare approved compendia indicates an Orphan Drug designation for this drug in neuroendocrine tumors. Per Medicare rules, this is considered a medically acceptable indication.A physician reviewed the appeal and determined that the plan is required to cover Octreotide.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jakafi 25 milligram tablet prescribed two times per day for diffuse alopecia areata. 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 doctor prescribed Jakafi to treat the enrollees diffuse alopecia areata. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Jakafi.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil 20 milligram tablets prescribed for pulmonary hypertension, World Health Organization group III. 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.The submitted documentation indicates the prescriber ordered Sildenafil for pulmonary hypertension, World Health Organization group III. 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 2.5 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

The enrollee requested Tylenol Extra Strength 500 milligram tablet. The Part D plan denied the enrollees 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 record shows the enrollee received Tylenol Extra Strength as a self-administered drug while in the hospital. According to Medicare rules, drugs that are considered over-the-counter are excluded from coverage under Part D. Tylenol Extra Strength is on Medicares excluded list of drugs because it is an over-the-counter medication. Therefore, we determined that the Part D plan is not required to cover or reimburse the Enrollee for Tylenol Extra Strength.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Dupixent 300 milligram/2 milliliter prescribed for moderate to severe atopic dermatitis 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 medical records show Dupixent was prescribed to treat atopic dermatitis. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of the requested drug for the enrollee's condition: Food and Drug Administration indications for Dupixent include atopic dermatitis, moderate to severe, not adequately controlled with topical prescription therapies or when those therapies are inadvisable.The records show that the enrollee cannot take other drugs on the plans formulary for atopic dermatitis. Specifically, tacrolimus ointment and pimecrolimus cream. DrugDex includes a Black Box Warning that long-term safety of topical calcineurin inhibitors has not been established and rare cases of malignancy (eg, skin and lymphoma) have been reported in patients treated with topical calcineurin inhibitors, including tacrolimus ointment and pimecrolimus cream.A physician reviewed your appeal and determined that an exception can be granted to cover the drug that is not on your plans formulary. Therefore, the plan is required to Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq 50 milligram extended release tablet 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 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. Myrbetriq is a brand drug on Tier 4 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 Dulera 200-5 microgram/aerosol prescribed twice daily for asthma. 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. 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. The physician states the enrollee has not tried any drugs on the formulary.A physician reviewed the appeal and determined that the plan is not required to cover Dulera.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vasculera Tablet prescribed for chronic peripheral venous insufficiency. 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 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. Medical foods do not meet the definition of a Part D drug. This is excluded from Part D drug coverage.A physician reviewed your appeal and determined that the plan is not required to cover Vasculera.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Corlanor 5 milligram tablets prescribed to treat autonomic dysfunction, postural orthostatic tachycardia syndrome, and coronary artery disease. The Part D plan denied the 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 Corlanor 5 milligram tablets to treat autonomic dysfunction, postural orthostatic tachycardia syndrome, and coronary artery. 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 Corlanor 5 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Sensipar 30 milligram tablet prescribed daily for the treatment of end stage renal 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. According to Medicare rules, the requested drug cannot be approved for separate payment under Part D when it's for treatment on a patient who is receiving dialysis. Medicare records show the enrollee is actively receiving dialysis. Therefore, the Sensipar must be billed by the renal dialysis facility. We determined that the plan is not required to cover the Sensipar. Please submit your request for this drug through the dialysis provider.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine Hydrochloride 5-milligram tablet to treat other muscle spasm.  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.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. 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. 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 Levothyroxine Sodium 88 microgram tablet 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.The record shows the enrollee purchased Levothyroxine Sodium from a preferred pharmacy for an amount that is less than or equal to the required copayment amount for date of service April 26, 2021. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charged you. The plan paid its share of the cost for the covered drug and you were responsible for the copay. We determined your copay for Levothyroxine Sodium was calculated correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Promethazine Hydrochloride 25 milligram suppository prescribed for nausea and vomiting. 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 medical records indicate that Promethazine Hydrochloride suppositories are prescribed as needed for nausea and vomiting. 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 Promethazine Hydrochloride.