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

At issue is a request for coverage of Metaxalone 800 milligram tablet prescribed for other enthesopathies. 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 the prescriber to send us information regarding the enrollee's condition. We also asked for medical records or other documentation to show why the enrollee needs the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the enrollee.  However, we did not receive the documentation.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 received documentation to support why other drugs on the plans formulary would not work for the enrollee. 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 Metaxalone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Clonidine 0.2 milligram transdermal patches prescribed for the treatment of essential hypertension. 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. Clonidine 0.2 milligram transdermal patch is a generic drug on Tier 4 of the plans formulary. The prescriber has not addressed the generic drugs of the same type on the lower tier of the plans formulary to treat the enrollees condition as to whether the drugs have been tried and failed, or are contraindicated. Therefore, the tiering exception criteria have not been met. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier. The drug will continue to be covered at the Tier 4 copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ondansetron Hydrochloride 4 milligram tablet prescribed for nausea. 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 indicates that Ondansetron Hydrochloride is prescribed to treat nausea and vomiting from a long standing history of peptic ulcer disease and gastrointestinal reflux disease. 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 Ondansetron Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Benztropine Mesylate 0.5 milligram tablet prescribed for extrapyramidal disease. 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 the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. We received the documentation and included it in our review.The plan requires for continuation of Benztropine Mesylate that the enrollee have extrapyramidal symptoms and contraindication to the non-high risk alternative medication Amantadine.  The documentation includes clinical notes that do not support a contraindication for the use of Amantadine in the Medicare approved compendia. The plan's utilization criteria have not been met. A physician reviewed the appeal and determined that Benztropine Mesylate is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Horizant ER 600 milligram extended release tablets. 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 medical records submitted at reconsideration indicate that Horizant ER has been prescribed for the treatment of peripheral neuropathy secondary to liver cirrhosis, alcohol use, and possible prediabetes. However, the Medicare approved compendia do not contain any citations to support the use of Horizant ER for the treatment of peripheral neuropathy due to the noted conditions. 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 request for coverage of non-formulary Butalbital-Aspirin-Caffeine 50-325-40 mg capsules. The Part D plan denied the request because it was not possible to determine if the drug was being used for a medically accepted indication, as the prescriber did not provide a 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. During this review, a request was submitted to the prescriber to provide a diagnosis, to address the formulary alternative drugs, and to provide supporting medical records. The prescriber submitted the requested documentation.The newly submitted medical records indicate that Butalbital-Aspirin-Caffeine has been prescribed for the treatment of tension headaches, which is a medically accepted indication outlined in the Medicare approved compendia. However, Butalbital-Aspirin-Caffeine is not included in the plans formulary (list of covered drugs). 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 the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lipitor 10 milligram tablets 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.Lipitor is a brand drug on Tier 3 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 Nucala 100 milligram/milliliter solution pre-filled syringe prescribed as directed for severe asthma with an eosinophilic phenotype. 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 Nucala.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Droxidopa 100 milligram capsules, 450 capsules per 30 days. The Part D plan denied the request for coverage because the amount requested exceeded the plans quantity limit. Additionally, the drug was being prescribed for a non-medically accepted indication.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 records indicate that Droxidopa has been prescribed for the treatment of orthostatic hypotension. However, as outlined in the Medicare approved compendia, Droxidopa is indicated in the treatment of neurogenic orthostatic hypotension caused by primary autonomic failure (e.g. Parkinsons disease, multiple system atrophy), dopamine beta-hydroxylase deficiency, or nondiabetic autonomic neuropathy. While the prescriber has submitted documentation stating that the enrollee does have neurogenic orthostatic hypotension, the submitted progress notes do not support that the enrollees orthostatic hypotension is being caused by primary autonomic failure, dopamine beta-hydroxylase deficiency, or nondiabetic autonomic neuropathy. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. Since the drug is not eligible for coverage under Medicare Part D, the plans quantity limit for the drug is not relevant to this review. 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 Tadalafil 5 milligram tablets. The Part D plan denied the request because the plans prior authorization requirements were not met.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 submitted medical records indicate that Tadalafil has been prescribed for erectile dysfunction. However, drugs when used for the treatment of sexual or erectile dysfunction are excluded from coverage under Medicare Part D. Therefore, the Tadalafil is not eligible for coverage under Medicare Part D. Since the drug is not eligible for coverage, the plans prior authorization requirements are not applicable to this review. 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 Tadalafil 5 milligram tablets prescribed to treat an enrollee with erectile dysfunction. 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 appeal request is for Tadalafil to treat erectile dysfunction. Medicare excludes certain drugs from Part D coverage. Tadalafil is an excluded drug when used to treat sexual or erectile dysfunction; or to treat a condition other than sexual or erectile dysfunction for which the drug has not been approved by the Food and Drug Administration. We determined that the plan is not required to cover Tadalafil. The record does not indicate that the plan provides supplemental coverage for Tadalafil. Therefore, the plan is not required to cover it. 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 Xeljanz Extended Release 11 milligram tablets prescribed for dermatopolymyositis, unspecified with myopathy. 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 Xeljanz is prescribed to treat dermatopolymyositis, unspecified with myopathy. 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 Xeljanz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Baclofen 10 milligram tablets. 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. The submitted medical records indicate that Baclofen has been prescribed for a hospice-related condition. Medicare Part A covers all drugs used in hospice treatment. A drug prescribed to a Part D eligible individual cannot be considered a covered Part D drug if payment for the drug is or would be available under Medicare Part A or Part B. Therefore, the Baclofen in 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 Albuterol Sulfate Nebulizer Solution 2.5 milligram/3 milliliter. 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. Albuterol Sulfate Nebulizer 2.5 milligram/3 milliliter is used via a nebulizer and the documentation indicates it will be used at home. This drug is not eligible for coverage under Part D drug benefits. However, this drug may be covered under Medicare Part B benefits. We determined that the plan is not required to cover Albuterol Sulfate Nebulizer Solution 2.5 milligram/3 milliliter.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ubrelvy 100 milligram tablet prescribed 1 tablet a day as needed for migraines without aura. 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 indicates Ubrelvy 100 milligram tablet is prescribed as needed for migraines. The prescriber also indicates the enrollee has tried Butalbital 50 milligram-Acetaminophen 300 milligram tablets which were not effective. However, the plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The prior authorization requirements have not been met. A physician reviewed your appeal and determined that the plan is not required to cover Ubrelvy.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Odactra 12 standardized quality (SQ) house dust mite (HDM) sublingual tablets. The Part D plan denied the request for coverage because the drug was being prescribed for a non-medically accepted indication. 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 submitted medical records/progress notes indicate that Odactra has been prescribed for the treatment of allergic rhinitis, specifically animal (cat, dog) hair and dander and pollen. However, the Medicare approved compendia do not contain any citations to support the use of the Odactra for the treatment of the noted conditions. At reconsideration, the prescriber has indicated that the enrollee has perennial allergic rhinitis due to dust mites. However, the previously submitted medical records do not indicate the enrollee has allergic rhinitis due to dust mites. Additionally, no medical records have been submitted at reconsideration to support the additional diagnosis of perennial allergic rhinitis due to dust mites. Therefore, there is insufficient documentation to determine if the requested drug is being prescribed for a medically accepted indication. As such, the requested drug 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 Xifaxan 550 milligram tablet prescribed for abdominal distention and flatulence. 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 indicates that Xifaxan 550 milligram tablet is prescribed to treat small intestinal bacterial overgrowth in an enrollee with multiple gastrointestinal complaints including gastroesophageal reflux disease. 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 Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methadone Hydrochloride 10 milligram tablet prescribed to take 4 tablets every 6 hours as needed for chronic facial pain due to a prior gunshot wound. The Part D plan denied the request as the amount was more than a 30 day supply.  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 prescriber indicates that they are not asking for more than 30 days supply but asking for 480 tablets per month and Methadone Hydrochloride is to treat pain for a gunshot wound to the face. However, the plan has a quantity limit of 240 tablets per 30 days. There is no documentation to support allowing more than the 240 tablets per 30 days that the plan allows.  A physician reviewed your appeal and determined that the plan is not required to cover Methadone Hydrochloride 10 milligram tablets with a quantity of 480 tablets per 30 days.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pimecrolimus 1% cream prescribed for lichen planopilaris. 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 indicates that Pimecrolimus 1% cream is prescribed to treat lichen planopilaris. 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 Pimecrolimus 1% cream.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Janumet 50-500 milligram tablets prescribed to treat Type 2 diabetes mellitus. 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.Janumet 50-500 milligram tablets is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. In this case, the medical records do not support why other drugs on the plans formulary would not work for the enrollee.A physician reviewed the appeal and determined that the plan is not required to cover Janumet 50-500 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trelegy Ellipta 100-62.5-25 micrograms per inhaler aerosol powder prescribed to treat asthma. 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.Trelegy Ellipta 100-62.5-25 micrograms 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 Methotrexate 25 milligrams per milliliter vial for intramuscular injection prescribed to treat an enrollee with ankylosing spondylitis. 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 Methotrexate 25 milligrams per milliliter vial for intramuscular injection to treat ankylosing spondylitis. 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 Methotrexate 25 milligrams per milliliter vial for intramuscular injection.