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

At issue is prescribed Oxycodone 20 milligram tablets 115 tablets/30 days, prescribed for lumbar radiculopathy, carpal tunnel syndrome, trochanteric bursitis of bilateral hips, and chronic right knee 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 records 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 this medication. We received the documentation and included it in our review.The plan requires for coverage of Oxycodone that the benefits outweigh the risks in elderly patients and an ongoing monitoring plan for ensuring safety be in place. The documentation includes clinical notes and a prescribers statement which satisfied the plan's coverage criteria. A physician reviewed the appeal and determined that the Oxycodone is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Otezla 30 milligram tablets prescribed as directed for Hurley stage 3 hidradenitis suppurativa. 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 Otezla to treat your Hurley stage 3 hidradenitis suppurativa. 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 Otezla.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydroxyzine Hydrochloride 10-milligram tablet to treat pruritus of the skin. 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, answers to prior authorization coverage criteria, and medical records. However, we did not receive the documentation.As such, no medical records were provided by the prescriber to support this diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Prednisone 5 milligram tablet prescribed daily to prevent kidney 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 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 the Prednisone. Medicare records indicate the enrollee received a kidney transplant on May 18, 2015, which was covered by Medicare Part A. Therefore, the transplant is considered a Medicare covered transplant and Prednisone is eligible under Medicare Part B. Medicare rules state that a drug covered under Part B cannot be covered under Part D. 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 Clonidine Hydrochloride 0.1 milligram extended release tablets prescribed for attention deficit hyperactivity disorder. 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.This medication is not on your plan's list of medications. The prescriber has not provided medical records that discuss why all medications required by the plan, on that list, did not work for you. This reason has to be in the medical record with details of when you tried those medications. The reason the medications on the formulary won't work or could cause you harm have to be stated. Why the other medications required by the plan will not work must be discussed. Therefore, an exception to the plans formulary coverage criteria is not supported. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tigecycline for Solution 50 milligrams. 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 also researched Medicare systems and reviewed the enrollment data available. We determined that the plan is not required to cover Tigecycline for Solution 50 milligrams. Medicare does not allow Part D drug plans to cover drugs produced by a manufacturer that does not participate in the Medicare Gap Discount Program. The Centers for Medicare & Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. Records show that the manufacturer did not sign the agreement and does not participate in the Medicare Gap Discount Program. Therefore, the Part D plan is not required to cover Tigecycline for Solution 50 milligrams. 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 Zolpidem Tartrate 10 milligram tablet prescribed to treat insomnia. 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 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 has prior authorization requirements for this drug that must be met before they will cover the requested drug. We requested additional information from the prescriber but did not receive a response. The prescriber has not sufficiently addressed the plans coverage criteria. The prescriber has not indicated why all alternatives required by the plan have been trialed and were not successful, with supporting medical documentation. The prescriber has also not indicated the required alternatives would likely cause harm or not be as effective as the requested drug.  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.A physician reviewed your appeal and determined that the plan is not required to cover Zolpidem Tartrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fosfomycin 3 gram sachet 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.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 Diclofenac Sodium 1% gel to be applied four times a day for chronic pain due to rheumatoid arthritis and right knee injury. The Part D plan denied the drug.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 doctor prescribed Diclofenac Sodium 1% gel to treat the enrollees chronic pain due to rheumatoid arthritis and right knee injury. The Medicare approved compendia do not support the use of this drug for the enrollees condition.A tiering exception was also requested. When a drugs prior authorization requirements are not met or the drug is not for a medically accepted indication, the drug is not eligible to be covered at a lower cost-share. We cannot consider a tiering exception for a drug for which the Medicare Part D plan is unable to provide coverage. Therefore, the plan is not required to cover Diclofenac Sodium 1% gel or to grant a tiering exception for this drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Desvenlafaxine Succinate Extended Release 50 milligram tablet prescribed for major depressive disorder. 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 prescriber has not sufficiently addressed the plans coverage criteria. The prescriber has not indicated why all alternatives required by the plan have been trialed and were not successful, with supporting medical documentation. The prescriber has also not indicated the required alternatives would likely cause harm or not be as effective as the requested drug.  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.  A physician reviewed your appeal and determined that the plan is not required to cover Desvenlafaxine Succinate Extended Release tablet. 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

The enrollee requested Sodium Chloride 0.9% solution. 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 determined that the plan is not required to cover the Sodium Chloride solution. Medicare does not allow Part D drug plans to cover drugs produced by a manufacturer that does not participate in the Medicare Gap Discount Program. The Center for Medicare and Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. Records show that the manufacturer for the Sodium Chloride did not sign the agreement and does not participate in the Medicare Gap Discount Program. 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

The enrollee requested Venofer 20 milligram/milliliter solution prescribed for unknown diagnosis. 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. According to Medicare rules, drugs that fall into the category of vitamins and minerals are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover the Venofer. There is no evidence the plan offers supplemental benefits for the Venofer. 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 Humalog KwikPen 200 units/milliliter injection 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. This drug is not included on your plans formulary. 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 Lidocaine 5% ointment prescribed for a shingles rash. 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 Lidocaine 5% ointment for a shingles rash. 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 Cayston 75 milligram inhalation solution prescribed for pseudomonas lung infection. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any information submitted at the reconsideration level. The prescriber indicates that Cayston 75 milligram inhalation solution is prescribed for bronchiectasis with frequent exacerbations and sputum cultures positive for Pseudomonas species. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Cayston.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydroxyzine Hydrochloride 50-milligram tablet. At initial determination and redetermination no diagnosis was given. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.At reconsideration a diagnosis of pruritus was given. No medical records were provided by the prescriber to support these diagnoses. Additionally, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these conditions. 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 Entresto 97 milligram-103 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.Entresto 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 Omeprazole 20 milligram delayed release tablets prescribed for dysphagia. 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 Omeprazole because it is an over-the-counter drug. 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: Favorable

At issue is Vascepa 1 gram capsule prescribed to treat coronary artery disease with elevated triglycerides. 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 records submitted at the reconsideration level.We asked the prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. The prescriber submitted prior authorization documentation along with supporting medical records.The medical records show the doctor prescribed Vascepa 1 gram capsule to treat coronary artery disease with elevated triglycerides. The enrollees plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The prescriber notes that the enrollee has a diagnosis of hyperglyceridemia with a pre-treatment triglyceride level of 150 t0 499 milligrams per deciliter. The documentation provided supports the enrollee has satisfied the plan's coverage criteria.A physician reviewed the appeal and determined that the plan is required to cover Vascepa 1 gram capsule, as the documentation supports the plans prior authorization requirements have been satisfied. The physician reviewer also determined that an exception to the plans prior authorization requirements can be granted.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Olopatadine Hydrochloride 0.2% ophthalmic solution prescribed for allergic rhinitis. 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 Olopatadine Hydrochloride because it is an over-the-counter drug. 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: Favorable

At issue is a prior authorization request for Forteo 620 milligram/2.48 milliliter injection prescribed for post-menopausal osteoporosis. 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. The medical records submitted indicate the enrollee was diagnosed with post-menopausal osteoporosis. The enrollee has a high risk of fragility fractures, has a pre-treatment T-score of less than -2.5, and has only completed 23 months of Forteo therapy. The documentation on hand indicates that the enrollee satisfies the plan's prior authorization coverage criteria.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amphetamine-Dextroamphetamine 20 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. Amphetamine-Dextroamphetamine 20 milligram tablet is a generic drug on Tier 3 of the plans formulary. The medical records do not support that all drugs available on lower tiers to treat your condition have been tried or deemed contraindicated. 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 Methylphenidate Hydrochloride 5 milligram tablets prescribed to treat moderate to severe apathy and chronic fatigue. 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 Methylphenidate Hydrochloride 5 milligram tablets to treat moderate to severe apathy and chronic fatigue. 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 Methylphenidate Hydrochloride 5 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dalfampridine Extended Release 10 milligram tablet prescribed for impaired mobility in an enrollee with multiple sclerosis. 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 Dalfampridine Extended Release tablets to impaired mobility in an enrollee with multiple sclerosis. 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 Dalfampridine Extended Release tablets. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.