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

At issue is Hyoscyamine Sulfate 0.125-milligram tablets prescribed for bladder spasms. 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 Orencia Click jet 125 milligram/milliliter injection prescribed as directed for moderate to severe rheumatoid arthritis. 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 your appeal and determined that the plan is not required to cover Orencia Click jet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrocortisone Acetate 25 milligram suppository to treat radiation proctitis. 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.The plan denied the request for coverage of the requested drug to treat the provided diagnosis because the plans Medicare Part D drug plan cannot cover drugs classified as being part of the Food and Drug Administrations Drug Efficacy Study Implementation (DESI) program. These drugs are considered to be Less than Effective (LTE) per Food and Drug Administration review.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is compounded drug, SM4 Azelaic Acid/Metronidazole/Ivermectin cream 15/18/1 percent 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 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 submitted documentation shows the requested is comprised of multiple ingredients that are reviewed individually. The enrollee provided a claim form for the requested drug including the National Drug Codes. We found that Azeliac Acid, Vanicream, Ivermectin, and Metronidazole have not been approved by the Food and Drug Administration for both safety and effectiveness. Therefore, they do not meet the definition of Part D drugs and are not eligible for coverage under Medicare Part D. The Tetrahydro Curcuminoids, Ethyl Alcohol, and sterile water are over-the-counter products and excluded for coverage under Part D. We determined the plan is not required to cover the requested compounded drug. 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: Favorable

At issue is Twinrix injection prescribed for shingles vaccination. 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 enrollee received the vaccine at the physicians office. The plans Evidence of Coverage states that payment for vaccines including administration fee is required up front from the enrollee when provided at an out of network pharmacy or provider's office. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The plans formulary shows the drug is covered as a Tier 2 drug. The documentation submitted includes a statement from the physicians office that shows the vaccine and administration fee was paid in full by the enrollee. Therefore, we determined that the plan is required to reimburse the enrollee for their share of the cost for the vaccine and administration fee.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ipratropium-Albuterol solution 0.5/2.5 (3)/milligram/3 milliliter solution prescribed for chronic obstructive pulmonary disease. The Part D plan denied the 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 Ipratropium-Albuterol 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 Ipratropium-Albuterol. 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 a prior authorization request for Xifaxin 550-milligram tablets prescribed for irritable bowel syndrome with diarrhea. The Part D plan denied coverage.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We requested additional information from the prescriber. Specifically, we requested medical records to substantiate the 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.On original appeal, the claim was denied as the prescriber submitted a diagnosis of irritable bowel syndrome without diarrhea. On appeal, the prescriber indicated the diagnosis was entered incorrectly and should be irritable bowel syndrome with diarrhea. A progress note was submitted to corroborate the change in diagnosis. However, the submitted documentation 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil Citrate 20 milligram tablet to treat erectile dysfunction. 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.Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not Food and Drug Administration (FDA) approved, are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a reimbursement request for Phentermine 37.5-milligram tablets. 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 reimburse Phentermine because it is a weight loss drug. Drugs to treat weight gain (promote weight loss) 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 Divigel 0.5-milligram gel packet prescribed as directed to treat vaginal symptoms of menopause. 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 your appeal and determined that the plan is not required to cover Divigel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dexilant 60 milligram tablets 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.Dexilant 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 a request for coverage of Stelara 90-milligram per milliliter prefilled subcutaneous injection syringe prescribed for the treatment of moderate to severe active ulcerative colitis. 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 the case file carefully. We reviewed all documentation submitted. The Part D plan has prior authorization requirements that have to be met before coverage of this drug is allowed. It is not possible to confirm that the plans coverage criteria have been satisfied with the available documentation. During this review, a request was submitted to the prescriber to address the plans prior authorization requirements and to provide supporting medical records. The prescriber did not respond to the request. The submitted documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan, with supporting medical documentation, would likely cause harm or not be as effective as the requested drug.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 Dupixent 300 milligram/ 2 milliliter pen injector to treat atopic dermatitis. 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 prescriber has provided patient specific clinical rationale and medical records. However, the documentation does not address 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 6.25-milligram extended release tablets. 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 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 to support 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 a request for coverage of Mayzent 2-milligram tablets 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. Mayzent is not included in the plans formulary (list of covered drugs). The prescriber has not provided sufficient clinical rationale as to why the alternative drug included in the plans formulary, Gileyna, 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 Esomeprazole Magnesium 40 milligram delayed release capsule prescribed as directed for gastro-esophageal reflux disease without esophagitis. 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 your appeal and determined that the plan is not required to cover Esomeprazole Magnesium.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Itraconazole 100-milligram capsule to treat tinea cruris. 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 asked your prescriber to send us a prescriber statement, a medically accepted indication (diagnosis), answers to prior authorization coverage criteria, laboratory and test results, and medical records. However, we did not receive the documentation.The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. 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 percent cream prescribed as directed for psoriasis. 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 Calcipotriene to treat your psoriasis. 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 Calcipotriene.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Evenity 105 milligram/1.17 milliliter prescribed as directed for age related osteoporosis at high risk for fracture. 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. 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. A physician reviewed your appeal and determined that the plan is not required to cover Evenity.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armour Thyroid 60-milligram tablets prescribed for the treatment of hypothyroidism unspecified. 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 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.Armour Thyroid has not been found by the Food and Drug Administration (FDA) to be safe and effective, and the drug product labeling had not been approved by the FDA. Drugs not approved by the FDA are excluded from Part D coverage. Therefore, the Medicare Part D plan is not required to cover the requested drug. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Gamunex-C 40-gram per 400-milliliter vial for intravenous infusion prescribed for the treatment of myasthenia gravis. 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. The plan has prior authorization requirements that must be met before coverage of this medication will be approved. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria have not been satisfied by the provided medical records. 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 Nuedexta 20-10 milligram capsules prescribed to treat the diagnoses of major depressive and anxiety disorders. The Part D plan denied the appeal 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 Nuedexta 20-10 milligram capsules to treat major depressive and anxiety disorders. 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 Nuedexta 20-10 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a quantity limit exception for Combigan 0.2-percent/0.5-percent eye drops (10-milliliters/7-days) prescribed for chronic angle-closure glaucoma. 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 prescriber statement to support the medical necessity for a quantity of supplies greater than the plans allowance. However, we did not receive the requested information.The documentation indicates the prescriber ordered the requested drug for the enrollees noted condition. The prescriber ordered a quantity of 10-milliliters per seven-days. The plan has a quantity limit restriction of 5-milliliters per 25-days on the requested drug. The submitted documentation does not support the medical necessity for a quantity greater than the plans allowance. Therefore, a quantity limit exception cannot be granted and the amount approved by the plan is upheld.The plan is not required to cover the requested drug for a quantity limit exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Albuterol Sulfate HFA 90-microgram/1-Actuation inhaler prescribed for mild intermittent asthma. 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 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 Albuterol Sulfate HFA.