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

At issue is Tramadol Hydrochloride Extended Release 200-milligram tablet Extended Release 24-Hour to treat pain related to polyosteoarthritis. 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. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nurtec 75 milligram oral disintegrating tablet prescribed for severe migraine 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 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 Nurtec 75 milligram oral disintegrating tablets for migraine headaches. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The medical records state that the enrollee has 15+ migraine headaches per month. The documentation does not show the plan's prior authorization coverage criteria has been met.  A physician reviewed your appeal and determined that the plan is not required to cover Nurtec. 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 Ubrelvy 50-milligram tablet to treat migraine with aura, not intractable, without status migrainosus. 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. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vimpat 100 milligram tablets 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.Vimpat 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

You requested Flector 1.3 percent transdermal 12-hour patch prescribed as directed for chronic pain. 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 Flector to treat your chronic pain. 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 Flector.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Cresemba 186 milligram capsule prescribed twice daily for mucormycosis. 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 Cresemba to treat the enrollees mucormycosis. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of this drug for this condition: Isavuconazonium sulfate (Cresemba) is indicated for the treatment of invasive mucormycosis in patients 18 years or older.The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The records show that the enrollee had a biopsy positive for Rhizopus oryzae, or mucormycosis, and there were no concomitant conditions documented. The documentation provided shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed the appeal and determined that the plan is required to cover Cresemba.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine 5 micrograms per hour patch prescribed every week for low back pain. 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. The physicians note states no other drugs tried and failed.A physician reviewed this appeal and determined that the plan is not required to cover Buprenorphine 5 micrograms per hour patch.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Sodium Chloride 0.9% vial prescribed for unknown diagnosis. 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 Sodium Chloride 0.9% is an ingredient within a compounded drug that is reviewed individually. The active ingredient within the compounded drug is not eligible for Part D coverage because it is excluded from coverage by the Food and Drug Administration. Therefore, we determined that the plan is not required to cover the Sodium Chloride 0.9% vial or provide reimbursement. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Panzyga 10 grams per 100 milliliters solution prescribed to treat diffuse eosinophilic fasciitis and eosinophilia. 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 documentation shows the doctor prescribed Panzyga 10 grams per 100 milliliters solution to treat diffuse eosinophilic fasciitis and eosinophilia. 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 Panzyga 10 grams per 100 milliliters solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Capecitabine 500 milligram tablets prescribed for metastatic breast cancer. 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 record shows the physician prescribed Capecitabine for metastatic breast cancer. The Medicare approved compendia support this is a medically accepted indication for the drug. However, the drug at issue is an oral cancer drug that has the same active ingredient as an injectable drug. Oral cancer drugs that contain the same active ingredient as injectable dosage forms are covered under Medicare Part B. The drug at issue is not considered a Part D benefit.We determined that the plan is not required to cover the Capecitabine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Victoza 0.6 milligram/0.1 milliliter 3-pack pen injector prescribed as directed. 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. Victoza 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 Repatha Sureclick 140 milligram/milliliter pen injector prescribed for hyperlipidemia. 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 biologic 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. A physician reviewed your appeal and determined that the plan is not required to cover Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Advair HFA 115-21-microgram Inhaler to treat chronic obstructive pulmonary 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.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. 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 Budesonide-Formoterol Fumarate 80-4.5 microgram inhalant prescribed for shortness of breath and post viral syndrome. 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 Budesonide-Formoterol Fumarate for shortness of breath and post viral syndrome. 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 Sublocade 300-milligrams/milliliter Subcutaneous to treat opioid dependence for a tiering exception.  The case was auto-forwarded by the plan.  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. This drug is provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are 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 Hydroxyzine Hydrochloride 10 milligram tablets prescribed to treat insomnia.  The case was auto-forwarded by the plan.  The 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 Hydroxyzine Hydrochloride 10 milligram tablets to treat insomnia. 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 Hydroxyzine Hydrochloride 10 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydroquinone 4% cream prescribed daily for lichen planus and post-inflammatory pigmentary change. 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 determined that the plan is not required to cover Hydroquinone 4% cream because it is not a Food and Drug Administration approved drug. Drugs not covered by the Food and Drug Administration are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, they 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 Autologous Serum Tears 20% eye drops. 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 drug at issue is a compound drug. The individual components of the compound are excluded from coverage as they are only to be used incident to a procedure. This is eligible for coverage under Part B. 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 Fexofenadine Hydrochloride 180 milligram tablets prescribed for otitis media. 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 Fexofenadine Hydrochloride because it is an over-the-counter medication. Nonprescription or over-the-counter drugs 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 Hydroxyzine Hydrochloride 50 milligram tablets prescribed for insomnia. 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 submitted documentation indicates the prescriber ordered Hydroxyzine Hydrochloride for insomnia. 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 Pyridium 200 milligram tablets prescribed for cystitis. 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 drug at issue is not Food and Drug Administration approved. 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 Cholecalciferol 25 microgram tablets prescribed for vitamin D deficiency. 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 Cholecalciferol because it is a prescription vitamin product. Drugs prescribed for prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations 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 Sildenafil Citrate 20 milligram tablets prescribed for erectile dysfunction. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We determined that the plan is not required to cover Sildenafil Citrate because it was prescribed for erectile dysfunction. Drugs prescribed for the treatment of sexual or erectile dysfunction 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 Albuterol Sulfate Nebulizer Solution 2.5 milligram/3 milliliter prescribed for unspecified asthma, uncomplicated. 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 records indicate the drug will be used in a nebulizer at home. This drug is not eligible for coverage under Part D drug benefits. However, this drug may be covered under Medicare Part B benefits. We determined that the plan is not required to cover Albuterol Sulfate Nebulizer Solution 2.5 milligram/3 milliliter.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azelaic Acid 15 % gel prescribed for acne vulgaris. 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. 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 documentation shows Azelaic Acid 15% gel was prescribed to treat acne vulgaris. 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 Azelaic Acid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate 250 milligram capsule prescribed every 12 hours for prophylaxis of liver transplant rejection. 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 states the enrollee had a Medicare covered liver transplant. Therefore, the Mycophenolate is eligible for coverage under Medicare Part B. Medicare Part B covers prescription drugs used in immunosuppressive therapy furnished to an enrollee who received an organ transplant. Drugs which are eligible for Part B coverage are excluded from Part D coverage by Medicare law. We determined that the Medicare Part D plan is not required to cover Mycophenolate. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit. Please submit your request to Medicare Part B.