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

At issue is FML Forte 0.25% eye drops prescribed for blepharitis of the lower eyelids. The Part D plan denied the request because the drug is not included on the plans formulary. 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 FML Forte was prescribed for treatment of blepharitis of the lower eyelids. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. Therefore, an off formulary exception will not be considered.A physician reviewed your appeal and determined that the plan is not required to reimburse FML Forte.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azathoprine 50 milligram tablet prescribed three times daily for ocular cicatricial pemphigoid. 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 documentation shows the doctor prescribed Azathoprine to treat the enrollees ocular cicatricial pemphigoid. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Azathoprine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for Lantus Solostar 100 units/3 milliliter, 60 per 1 day. The Part D plan denied the request because it exceeded the plan's quantity limit.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 submitted includes Lantus Solostar 100 units/3 milliliter, 60 per 1 day listed on an emergency room itemization. However, without a diagnosis it cannot be established that Lantus Solostar is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. Therefore, Lantus Solostar is not eligible for coverage under Medicare Part D.  A physician reviewed your appeal and determined that the plan is not required to reimburse Lantus Solostar.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is AndroGel 1.62%, 20.25 milligrams per actuation pump gel prescribed daily for hypogonadotropic hypogonadism. 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 Androgel 1.62% to treat the enrollees hypogonadotropic hypogonadism. DrugDex, a Medicare approved compendium, supports the use of this drug for this condition. However, 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 the prescribers statement that the formulary alternatives were tried. A physician reviewed the appeal and determined that the plan is not required to cover AndroGel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Insulin Aspart 100-units/3-milliliters Insulin Pen, 60-units/1-day. The Part D plan denied the request. 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.It is noted that your plan has a dosage quantity limit of 30-units/28-days for the Insulin Aspart. However, no medical records were provided by the prescriber. 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 not eligible for Part D coverage. As such, your plan is not required to reimburse you for the Insulin Aspart.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Tremfya 100 milligram per milliliter subcutaneous injection pen prescribed for the treatment of plaque psoriasis. 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. Tremfya is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale as to why the formulary alternatives included in the plan to treat the noted condition 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 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 a request for coverage of Sandostatin LAR Depot 20 milligram vial for intramuscular injection. 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 documentation indicates that Sandostatin LAR Depot has been prescribed for the prevention of gastric arteriovenous malformation and gastrointestinal bleeding in an enrollee with an implanted left ventricular assist device. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. 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 tiering exception request for Levemir Flex Touch 100-units/milliliter (3-milliliters) Subcutaneous Pen to treat Type 2 diabetes mellitus with complications. 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 drug is being 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.Our physician reviewer's opinion is that non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Restasis 0.05% ophthalmic dropperettes prescribed for the treatment of keratoconjunctivitis sicca. 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. Restasis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine Hydrochloride Urethral/Mucosal 2% Gel. At initial determination and redetermination the diagnosis of neoplasm related to pain acute and chronic 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 diagnoses of other and unspecified malignant neoplasm of skin of trunk and extramammary Pagets disease skin of groin were given. No medical records were provided by the prescriber to support these diagnoses. It could not be determined whether the requested drug was being prescribed for medically accepted indications. 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 a request for coverage of Enbrel Mini 50 milligram per milliliter solution cartridge prescribed for the treatment of moderate to severe rheumatoid arthritis. 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 coverage criteria are not satisfied by the provided medical records, as there is no confirmation in the medical records that the enrollee was screened for latent tuberculosis infection prior to initiation of treatment. 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 Vyvanse 60 milligram capsules prescribed to treat idiopathic hypersomnia. 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 Vyvanse 60 milligram capsules to treat idiopathic hypersomnia. The prescriber sent a statement dated 7/22/2021 clarifying the diagnosis. 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 Vyvanse 60 milligram capsules.
Appeal type: Prescription Drug
Decision: Favorable

The enrollee requested Ventolin HFA AER 20 microgram/ACT prescribed for unknown diagnosis. The Part D plan denied your 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 enrollee was given Ventolin HFA AER Inhaler while in the emergency room. According to the plan's Evidence of Coverage, 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 documentation submitted includes a receipt showing the enrollee paid for the Ventolin HFA AER Inhaler. We determined that the plan is required to reimburse the enrollee for their share of the cost for the Ventolin HFA AER Inhaler.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Lidocaine 5% patches prescribed for osteoarthritis knee pain. 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.As outlined in the Medicare approved compendium, DrugDex, the use of Lidocaine 5% patches to treat osteoarthritis pain is acceptable in certain situations, depending on such things as the location, etiology, and duration of the pain. During this review, a request was submitted to the prescriber with questions pertaining to the required elements for the coverage of Lidocaine patches to treat osteoarthritis pain. The diagnosis was clarified but medical records to support the diagnosis were not submitted.  Without medical records, it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested Lidocaine patch is not eligible for coverage under Medicare Part D. 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 Ofev 150 milligram capsules prescribed for the treatment of idiopathic pulmonary fibrosis. 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 Part D plan has prior authorization requirements that must be met before coverage of this medication will be approved for the noted condition. 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 a tiering exception request for Eliquis 5 milligram tablets prescribed for anticoagulation therapy due to a history of transient cerebral ischemic attack. 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. Eliquis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Entresto 49-52 milligram tablets prescribed to treat chronic heart failure. 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 medical record shows the doctor prescribed Entresto 49-52 milligram tablets to treat chronic systolic heart failure, New York Heart Association Classification II heart failure. The enrollees plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation shows Entresto is for the continuation of therapy to treat chronic heart failure. Additionally, the prescriber indicates that the enrollee does not have a history of angioedema related to previous angiotensin-converting enzyme (ACE) inhibitor or angiotensin-receptor blocker (ARB) therapy; and, will not use the requested drug with or within 36 hours of an ACE inhibitor. The documentation supports the enrollee has satisfied the plan's coverage criteria.A physician reviewed the appeal and determined that the plan is required to cover Entresto 49-52 milligram tablets, as the plans prior authorization criteria has been satisfied. The physician reviewer also determined that an exception to the plans prior authorization requirements can be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Zolpidem Tartrate 10 milligram tablets prescribed for insomnia. 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 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 a request for coverage of Ketamine Hydrochloride 40 milligram compounded capsules prescribed for the treatment of chronic 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.The requested drug is a compounded drug that contains bulk powders. Bulk powders do not satisfy the definition of a Part D drug and are not covered by Part D. Therefore, the Ketamine Hydrochloride does not meet the definition of a Part D drug and is not eligible for coverage under Medicare 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 Oxymorphone Hydrochloride ER 40 tablet prescribed twice daily for chronic intractable residual post-operative low back pain with radiation to bilateral lower extremities. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication was needed. We received the documentation and included it in our review.The doctor prescribed Oxymorphone Hydrochloride ER to treat the enrollees chronic intractable residual post-operative low back pain. The 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 the appeal and determined that the plan is not required to cover Oxymorphone Hydrochloride ER. 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 Droxidopa 200 milligram tablet prescribed three times daily for neurogenic orthostatic hypotension. 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 documentation shows the doctor prescribed Droxidopa to treat the enrollees neurogenic orthostatic hypotension. However, the Medicare approved compendia do not support the use of this drug for this enrollee.A physician reviewed the appeal and determined that the plan is not required to cover Droxidopa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armour Thyroid 120 milligram tablet prescribed daily for acquired hypothyroidism. 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 Armour Thyroid because it is not approved by the Food and Drug Administration. Drugs not approved by the Food and Drug Administration are excluded from coverage. Per Drugdex, a Medicare approved compendia, This drug has not been found by the United States Food and Drug Administration to be safe and effective, and the drug product labeling has not been approved by the Food and Drug Administration. If the enrollee purchased drugs that are excluded, they must pay for them yourself. 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

You requested Lidocaine 5% patch for dorsalgia and chronic back pain due to neuropathy. 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 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 did not receive the documentation requested.The documentation shows Lidocaine 5% patch was prescribed to treat dorsalgia and chronic back pain due to neuropathy. 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 Lidocaine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Velphoro 500 milligram tablets prescribed for disorders of phosphorous metabolism. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. We received the documentation and included it in our review. 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, we did not receive medical records to 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 Velphoro.