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

You requested Mycophenolate Mofetil prescribed as directed for autonomic ganglionopathy. 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 Mycophenolate Mofetil to treat your autonomic ganglionopathy. 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 Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rifaximin 550-milligram tablet to treat small intestinal bacterial overgrowth. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq 50 milligram extended-release 24-hour 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.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 Caplyta 42 milligram capsule prescribed for bipolar 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.The medical records show the doctor prescribed Caplyta to treat the enrollees bipolar disorder. 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 Caplyta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fluocinonide 0.05% Solution to treat other seborrheic dermatitis. 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.The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary alternatives required by the plan would likely not be as effective as the requested drug for this condition, and/or would likely cause adverse reaction(s) or other harm.  Therefore, an exception to the plans formulary coverage criteria is not medically necessary. 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 Aspirin 81 milligram chewable tablet.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 Aspirin as a self-administered drug in the hospital emergency room. According to Medicare rules, drugs that are considered over-the-counter are excluded from coverage under Part D. Aspirin is an over-the-counter medication. There is no evidence that the enrollee has supplemental coverage for the Aspirin. Therefore, we determined that the Part D plan is not required to cover or reimburse the enrollee for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Finasteride 1 milligram tablet prescribed for retention of urine associated with benign prostatic hyperplasia. 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.Finasteride 1 milligram tablet is not on the plan's formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.A physician reviewed your appeal and determined that the plan is not required to cover Finasteride 1 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested TDVAX 2/2/LF/0.5 milliliter suspension prescribed for vaccination. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The plan submitted documentation that shows the enrollee was still in the deductible stage of the Part D benefit when the vaccine was administered at the physicians office. The plans Evidence of Coverage states that the enrollee is responsible for the full cost of covered drugs until the deductible amount is satisfied. We determined that the amount the enrollee paid was correctly applied to the deductible and no reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Enbrel 50 milligram per milliliter Sureclick prescribed for lichen planus and seborrheic 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 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 show the doctor prescribed Enbrel to treat the enrollees lichen planus and seborrheic dermatitis. 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 Enbrel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pennsaid 2% solution prescribed for bursitis of the knee. 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 Pennsaid 2% solution prescribed for bursitis of the knee. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Pennsaid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lubiprostone 8 microgram capsules prescribed to treat opioid-induced constipation in chronic non-cancer pain. The Part D plan denied the appeal request.The QIC received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported. 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 Lubiprostone 8 microgram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140-milligrams/milliliter Solution Auto-Injector to treat hyperlipidemia, unspecified. 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.The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary alternatives required by the plan would likely not be as effective as the requested drug for this condition, and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not medically necessary. 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 Calcipotriene 0.005% cream prescribed for guttate psoriasis. 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 show the doctor prescribed Calcipotriene to treat the enrollees guttate psoriasis. 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 Calcipotriene.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vumerity DR 231 milligram delayed release capsules prescribed for the treatment of multiple sclerosis. 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. Vumerity DR 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 all the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ozempic 0.25 or 0.5 milligram pen injector. 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. 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 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 Invokana 100 milligram 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. Invokana 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

At issue is Prempro 0.3-1.5 milligram tablet prescribed daily for hot flashes. 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.Prempro 0.3-1.5 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 the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium 3% Gel to treat chronic pain. The Part D plan denied the request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.A request was submitted to the prescriber to provide a diagnosis, to address the prior authorization criteria, to address the quantity limit criteria, and to provide supporting medical records.  We received the prescriber statement and prior authorization answers. The record shows you were prescribed Diclofenac Sodium 3% Gel to treat your chronic pain associated with lumbar spondylolisthesis, occipital neuralgia and cervicalgia. 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

The enrollee requested Creon 24000 unit capsule prescribed daily 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 you received Creon from the mail-order pharmacy and was charged an amount that is less than or equal to the required coinsurance amount. We reviewed the plans formulary and Evidence of Coverage. In this case, the documentation shows you were in the coverage gap stage when your refill of the tier 3 drug Creon was processed. The plan paid its share of the cost for the covered drug and the enrollee was responsible for their share of the remaining 25%. We determined that the plan calculated the enrollees cost share in the coverage gap stage correctly and no additional reimbursement is required.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Botox 200 unit for solution 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 drug was supplied by the prescriber and administered to the enrollee in the prescribers office. According to Medicare rules, Part B pays for services and supplies from physician and/or office stock supply, and should be billed as part of a physician service. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined that the plan is not required to cover the Botox. Please consider submitting your 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 Januvia 100 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.Januvia 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 a request for coverage of Repatha SureClick 140 milligram per milliliter subcutaneous injection pen prescribed for pure hypercholesterolemia and chronic ischemic heart disease. 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. Repatha SureClick 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 included in the plan would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm.  A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Fenofibrate 120 milligram tablets prescribed for pure hyperglyceridemia. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We requested additional information from the prescriber. Specifically, we requested medical records and a supporting statement to indicate all formulary alternatives were tried and failed. However, we did not receive the documentation.The documentation on hand did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Fenofibrate 120 milligrams.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Imvexxy 4 microgram vaginal capsules prescribed for vulvar burning. 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 Imvexxy for vulvar burning. The Medicare approved compendia do not support the use of the drug at issue, as prescribed, 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 Welchol 625 mg tablets prescribed as directed for hyperlipidemia. 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. However, we did not receive the documentation.In order to grant an exception for a drug not on the plans formulary, all 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 Welchol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rhopressa 0.02% ophthalmic solution prescribed for glaucoma. 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 prescriber indicates that they prescribed Rhopressa 0.02% ophthalmic solution to treat glaucoma. However, there was no documentation that the enrollee had tried or cannot use a prostaglandin analog. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation was not provided to 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 Rhopressa 0.02%. 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 prior authorization request for Testosterone 1% gel pump prescribed for hypogonadism. The Part D plan denied coverage.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We requested additional information from the prescriber. Specifically, we requested medical records and a supporting statement to indicate the enrollee met the plans prior authorization coverage criteria. However, we did not receive the documentation.The documentation on hand does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.