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

At issue is Cyclobenzaprine Hydrochloride 10 milligram tablets prescribed for dorsalgia and sleep. 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 indicates the prescriber ordered Cyclobenzaprine Hydrochloride for dorsalgia and sleep. 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 a request for coverage of Ondansetron 4 milligram orally disintegrating 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 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 indicates that Ondansetron has been prescribed for the treatment of nausea and vomiting due to gastroesophageal reflux disease and gastroparesis. 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 conditions. 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 requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Acetylcysteine 20% solution prescribed for the treatment of a cough. 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 Acetylcysteine is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover the Acetylcysteine. Please consider submitting this request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Restasis 0.05% eye drops 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.Restasis 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 Diclofenac Sodium 1% topical gel prescribed for pain in leg due to cellulitis. 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 indicates the prescriber ordered Diclofenac Sodium 1% topical gel for pain in leg due to cellulitis. 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 a request for coverage of Terbinafine Hydrochloride 250 milligram tablets, 90 tablets per 90 days, prescribed for chronic toenail fungal infection. 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 part D plan has a quantity limit for Terbinafine Hydrochloride of 90 tablets per year. The documentation does not support the necessity for exceeding the maximum dose allowed by the plan. An exception to the quantity limit criteria has not been met. A physician reviewed the appeal and determined that the plan is not required to cover more than 90 tablets of Terbinafine Hydrochloride per year.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Butorphanol 10 milligram per milliliter nasal spray, 10 milliliters per 10 days, prescribed for chronic cluster headaches. 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 record indicates that the enrollee has prescriptions for Hydrocodone-Acetaminophen 10-325 milligrams and Morphine Sulfate ER 15 milligrams, in addition to the Butorphanol nasal spray. The use of these medications together can cause unsafe side effects. The prescriber has submitted progress notes at reconsideration stating that the enrollee has agreed to refrain from using the Hydrocodone-Acetaminophen and Morphine Sulfate while using the Butorphanol. However, the total opioid dose the enrollee has on hand requires an attestation from the prescriber to support that the amount of medication containing opioids that the enrollee has on hand is medically necessary. The prescriber has noted that the severity, onset, and duration of the enrollees symptoms requires the use of the Butorphanol. However, the prescriber has not addressed why it is medically necessary for the enrollee to have Hydrocodone-Acetaminophen and Morphine Sulfate ER on hand at the same time as the Butorphanol. Furthermore, the prescriber has requested 10 milliliters per 10 days of Butorphanol nasal spray, which exceeds the maximum dose usually allowed of 5 milliliters per 28 days. The prescriber has not addressed why the enrollee would need to exceed the maximum dose allowed. A physician reviewed the appeal and determined that the plan is not required to cover more the Butorphanol nasal spray.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Revlimid capsule 10 milligram prescribed for chronic cutaneous systemic lupus erythematosus. 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 Revlimid was prescribed to treat chronic cutaneous systemic lupus erythematosus. However, the Medicare approved compendia do not support the use of this drug for the enrollee's condition. A physician reviewed your appeal and determined that the plan is not required to cover Revlimid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Myrbetriq 50-milligram Extended Release 24-Hour tablet to treat benign prostatic hyperplasia. 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.Myrbetriq is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Omega 3-Acid 1000-milligram capsule to treat an unknown diagnosis. 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.In the Reconsideration appeal medical records were requested.  No medical records were provided.  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 requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tizanidine 6-milligram capsule. At initial determination and redetermination the diagnosis of cervical disc disorder with radiculopathy and neuritis, radiculitis, or radiculopathy. 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.At reconsideration a diagnosis of spasm of cervical paraspinous muscle was given. 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 medically accepted indications. 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 Tretinoin 0.025% cream prescribed for rhytides. 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 medical records show Tretinoin was prescribed to treat rhytides (fine wrinkles). Drugs prescribed for cosmetic purposes are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverageA physician reviewed your appeal and determined that the plan is not required to cover Tretinoin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Modafinil 100 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 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 indicates that Modafinil has been prescribed for unspecified hypersomnia and malaise and fatigue status post cerebral infarction. 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 conditions. Therefore, the drug is being prescribed for non-medically accepted indications 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 requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Stelara 90 microgram per milliliter prefilled subcutaneous injection syringe. 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 documentation indicates that Stelara has been prescribed for the treatment of hidradenitis suppurativa. 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 requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tizanidine HCL 2 milligram capsule prescribed to treat muscle spasm. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the prescribers statement does not support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Tizanidine HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for a Flovent HFA 110 microgram per actuation inhaler. 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. Flovent HFA 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. 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 the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jardiance 10 milligram tablet. 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 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 the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eplerenone 50 milligram tablets prescribed for hypertension. 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. Eplerenone is a generic drug on Tier 4 of the plans formulary. The prescriber has not indicated if all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug.  Therefore, this drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nourianz 20-milligram tablet to treat Parkinsons disease. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 medication is not on your plan's list of medications. The prescriber has not given a clear and valid 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. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jentadueto 2.5-1000 milligram tablet prescribed twice daily. 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. Jentadueto 2.5-1000 milligram tablet 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

The enrollee requested Omeprazole 20 milligram capsule as part of compounded Omeprazole 2 milligram/milliliter solution prescribed for gastroesophageal reflux disease. 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 Omeprazole solution is a compounded drug and each ingredient is reviewed individually. Medicare Part D does not cover drugs that are not properly listed with the Food and Drug Administration. The active ingredient within the compounded drug is not eligible for Part D coverage. Therefore, we determined the plan is not required to cover Omeprazole or provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Relistor 12-milligram/0.6-milliliter solution for subcutaneous injection. At initial determination and redetermination the diagnosis of chronic constipation causing functional bowel obstruction was given. 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.At reconsideration the diagnosis of drug induced constipation was given. The documentation provided addressed the plans coverage criteria, and those criteria were not satisfied. An oral medication specifically for opioid induced constipation has not been trialed and failed, or deemed likely to be ineffective or harmful.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 a request for coverage of Patanase 665 microgram nasal spray prescribed for seasonal allergic rhinitis. 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. Patanase nasal spray is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives that are 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. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregabalin 50 milligram capsule prescribed daily for pain in right and left leg and unspecified neuropathy. 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 documentation shows the doctor prescribed Pregabalin to treat the enrollees right and left leg pain and unspecified neuropathy. However, the Medicare approved compendia do not support the use of this drug for these conditions. A physician reviewed the appeal and determined that the plan is not required to cover Pregabalin.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Entresto 24-milligram-26-milligram tablet. to treat chronic systolic heart failure.   At initial determination and redetermination the diagnoses of a history of angioedema related to previous angiotensin-converting-enzyme inhibitor (ACE) or angiotensin receptor blocker (ARB) therapy and chronic systolic heart failure were given.  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.  In the Reconsideration appeal the prescriber clarified their answers to the PA questions and sent supporting office notes dated 7/1/2021.  The enrollee does not have a history of angioedema related to previous angiotensin-converting-enzyme inhibitor (ACE) or angiotensin receptor blocker (ARB) therapy.The documentation satisfies the plans coverage criteria.  A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.