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

At issue is Zolpidem Tartrate 10 milligram tablet to treat insomnia. The Part D plan denied the request. 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. 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 documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed, with support of medical records, the issues regarding this high-risk medication, and why alternative safer medications, in the plan's formulary, could not be used. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Caplyta 42 milligrams capsules prescribed to treat the enrollees condition. 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.Caplyta is on Tier 5 of the plans formulary. This tier is identified as a Specialty Tier. The plan is not required to grant a tiering exception for drugs available on their Specialty Tier. Therefore, a tiering exception cannot be considered.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 Sucraid 8500-units/milliliter to treat sucrase-isomaltase deficiency. 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 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

You requested Promethegan 25 milligram suppository prescribed as directed for nausea associated with migraines. 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 Promethagan to treat nausea associated with migraines.  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 Promethegan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyto Q 80 milligram/10 milliliter solution prescribed for Mitochondrial metabolism disorder. The Part D plan denied the request.   We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available over-the-counter (OTC) are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Sildenafil 20 milligram tablets prescribed as directed for pulmonary arterial hypertension. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Sildenafil to treat your pulmonary arterial hypertension, WHO functional class I. The documentation provided shows that the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Sildenafil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Octreotide Acetate 100 microgram/milliliter solution to treat fistula of intestine. 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 Octreotide Acetate was prescribed to treat an enterocutaneous fistula. 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 Octreotide Acetate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Eszopiclone 2-milligram tablets prescribed for chronic insomnia.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. The plan has prior authorization requirements that must be met before coverage of this drug will be approved. During this review, a request was submitted to the prescriber to address the plans coverage requirements and to provide supporting medical records. The prescriber answered the prior authorization questions. However, no medical records were submitted, as requested. Without medical records, it cannot be confirmed that the plans coverage criteria have been satisfied. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Humulin R 500-units/milliliter Vial to treat diabetes mellitus. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 drug is being provided by the plan at the cost sharing level of the Specialty tier. Specialty tier drugs are not available for a tiering exception per Medicare rules.A physician reviewed the request and determined that Specialty tier drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Spravato 56 milligram spray for the diagnosis of major depressive disorder. The Part D plan denied the request. We performed 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 psychotherapy office visit indicates the enrollee has major depressive disorder and the prescriber has recommended treatment with Spravato. However, this medication requires to be administered in a healthcare facility or with direct supervision of a healthcare provider. It is not eligible to be covered under the Medicare Part D prescription drug benefit. However, this drug may be covered under Medicare Part B benefits.A physician reviewed your appeal and determined that the plan is not required to cover Spravato.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is compounded drug Nifedipine/Lidocaine 0.5/2 percent ointment 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 reviewed 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 the compounded drug Nifedipine/Lidocaine 0.5/2 percent ointment. According to Medicare rules, drugs that fall into the category of bulk powders are excluded from coverage under Part D. Therefore, Nifedipine and Lidocaine are excluded from coverage. We reviewed Food and Drug Administration (FDA)-approved sources for the drugs classification or determined from other available resources that the Mineral Oil and Petroleum Jelly are over-the-counter drugs and therefore, not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xiidra 5 percent droperette prescribed as directed for dry eye syndrome of bilateral lacrimal glands with punctal plugs. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Xiidra to treat your dry eye syndrome of bilateral lacrimal glands with punctal plugs. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Xiidra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium Gel 3% prescribed for arthritis of the hands. 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 prescriber indicates Diclofenac Sodium Gel 3% is prescribed to treat arthritis of the right hand. However, Medicare approved compendia does not support the use of Diclofenac Sodium Gel 3% for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Diclofenac Sodium Gel 3%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Humalog Kwikpen 100-unit/milliliter prescribed for type 2 diabetes mellitus without complications. 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. We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support all formulary alternatives were tried and failed. However, we did not receive the requested information.The submitted documentation did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed the appeal and determined that the plan is not required to cover Humalog Kwikpen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch prescribed to treat the diagnoses of chronic low back pain and unspecified osteoarthritis. 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.We asked the prescriber to send us information regarding the enrollees condition. Specifically, we asked for diagnosis clarification, and medical records or other documentation to show why the enrollee needs this medication. We received the documentation and this will be included in our review.The documentation shows the doctor prescribed Lidocaine 5% patch to treat chronic low back pain and unspecified osteoarthritis of unspecified site. The documentation provided fails to support that the enrollee has met the criteria for a medically accepted indication per the approved Medicare compendia. Although additional documentation has been provided for review, this does not change the QICs initial decision.A physician reviewed the appeal and determined that the plan is not required to cover Lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Topiramate 50 milligram tablet prescribed for metabolic syndrome with abnormal weight gain. 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 indicate Topiramate 50 milligram tablet is prescribed to metabolic syndrome with abnormal weight gain. However, drugs used for anorexia, weight loss, or weight gain are excluded from Medicare Part D drug benefits.A physician reviewed your appeal and determined that the plan is not required to cover Topiramate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium 1-percent gel. 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 to support a prescribed diagnosis and a prescriber statement to support the enrollee satisfies the plan's prior authorization coverage criteria. However, we did not receive the requested information.The submitted documentation does not include medical records or evidence of a prescribed diagnosis. As it cannot be determined that the drug was 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 Cyproheptadine HCL 2 milligram/5 milliliter syrup to treat anorexia. The Part D plan denied the request. We performed 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 determined that the plan is not required to cover Cyproheptadine HCL because it was used to treat anorexia. Drugs used to treat anorexia, weight loss, or weight gain are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyzulta 0.024 percent ophthalmic solution 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. Vyzulta 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 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 Triazolam 0.25-milligram tablet to treat chronic insomnia. The Part D plan denied the request. The requested drug is not on the plans formulary. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 required by the plan, 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: Favorable

At issue is Omnipod Dash prescribed for type 2 diabetes mellitus, uncontrolled. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The prescriber submitted a statement supporting the enrollees medical necessity for Omnipod Dash. The Medicare approved compendium supports the use of the requested drug for your condition. There are no other insulin delivery systems on formulary.A physician reviewed the appeal and  determined that the plan is required to cover Omnipod Dash.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metformin HCL ER 1000 milligram tablet prescribed for diabetes mellitus.  The prescriber is requesting 360 tablets for 90 days. 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.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 amount of the medication. We received the documentation and included it in our review.The plan has allowed 60 tablets (1000 milligram) for 30 days. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the condition or would be likely to cause harm.  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: Unfavorable

At issue is Esterified Estrogens/Methyltesterone 1.25-2.5 milligram tablet prescribed for menopause symptoms. 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.Non-FDA approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.A physician reviewed your appeal and determined that the plan is not required to cover Estrogens/Methyltesterone 1.25-2.5 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At initial determination, Trelegy Ellipta 200-62.5-25 was prescribed for persistent severe asthma. The plan did not issue a determination, but indicated duplication of medication was possibly occurring.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. At redetermination a diagnosis of chronic obstructive pulmonary disease was submitted. No medical records were provided. We requested additional information from the prescriber but did not get all information requested, or the information provided was unreadable. In order to establish medical necessity and confirm that the requested drug is being used per the Food and Drug Administrations guidelines and per your plans criteria, additional information was required. The information was insufficient to fulfill these criteria. A physician reviewed your appeal and determined that the plan is not required to cover Trelegy Ellipta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nuedexta 20-10-milligram capsule to treat pseudobulbar affect associated with dementia. 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 FDA labeling, acceptable to determine a medically accepted indication per Medicare guidance, for Nuedexta, does not specify any limitations on underlying diagnosis. Therefore, the drug is being prescribed for a medically accepted indication. However, the plan has prior authorization criteria that must be met for coverage. The condition of pseudobulbar affect associated with dementia does not satisfy the plan's prior authorization criteria. Therefore, coverage for this drug is not approved. This decision does not speak to the medical necessity of this drug for your condition. This decision speaks to whether your plan is required to provide coverage under Medicare rules. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.