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

You requested Gammagard 30 grams/300 milliliter solution prescribed for hereditary and idiopathic neuropathy (small fiber peripheral neuropathy). 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 records show Gammagard 30 grams/300 milliliter solution was prescribed to treat hereditary and idiopathic neuropathy (small fiber peripheral neuropathy). 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 Gammagard 30 grams/300 milliliter solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Travatan Z 0.004% eye drops 2.5 milliliters per 22 days (sic) to treat bilateral primary open-angle glaucoma.   The Part D plan denied the request.  We received a reconsideration request.  The plan's Redetermination letter states that the drug has been approved as 2.5 milliliters per 25 days.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.  A request was submitted to the prescriber to clarify the requested quantity and to provide supporting medical records.  A reply from the prescriber was not received.The plan limits the amount of Travatan Z 0.004% eye drops to 2.5 milliliters per 25 days. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the condition or would be likely to cause harm.  Therefore, an exception to the plans coverage criteria is not supported.  Our physician reviewer's opinion is that quantity limit criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20-milligram capsule to treat non-24-hour sleep-wake disorder (Non-24). 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 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 Armour Thyroid 60 milligram tablets to treat hypothyroidism. 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.Non-Food and Drug Administration approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amphetamine-Dextroamphetamine ER 10 milligram capsule prescribed daily for attention-deficit hyperactivity 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. We asked your prescriber to send us information regarding your condition. We also asked for medical records  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 some of the documentation and included it in our review, however supportive medical records were not provided.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 Amphetamine-Dextroamphetamine ER 10 milligram capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xeljanz XR 11 milligram tablets prescribed for sarcoidosis. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates your doctor prescribed Xeljanz XR 11 for sarcoidosis. The use of the requested drug to treat the provided diagnosis is an off-label use.  The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your 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 Diclofenac Sodium 1% gel. 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.The documentation indicates that Diclofenac Sodium 1% gel has been prescribed for the treatment of palmar fascial fibromatosis of the left hand. 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 Diclofenac Sodium 1% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Armodafinil 250 milligram oral tablet prescribed daily for low energy drive due to 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 documentation shows your doctor prescribed Armodafinil to treat your low energy drive due to major depressive disorder. 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 Armodafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Skyrizi 75 milligram per 0.83 milliliter subcutaneous injection pens prescribed for plaques 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. The documentation does not satisfy the plans coverage criteria for this medication. 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 Nystatin 100,000 units per gram topical powder prescribed for intertrigo. The Part D plan denied the request because the medication 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 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.While the documentation initially submitted to the plan indicates the Nystatin powder was being prescribed for intertrigo, the prescriber has submitted a prescription at reconsideration for Nystatin powder for the enrollee that includes the diagnosis code for candidiasis of the skin. However, no medical records have been submitted to validate this change in diagnosis. During this review, a request was submitted to the prescriber to clarify the change in diagnosis and to provide supporting medical records. A reply from the prescriber was not received. Without supporting medical records, it cannot be established that the requested drug 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, the requested drug is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Avastin 100 milligrams/4 milliliters for intravitreal injection prescribed at a dosage of 1.2 milligrams monthly for panuveitis. 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 enrollees condition and the drug prescribed. We did not receive the documentation requested.The documentation shows the doctor prescribed Avastin to treat panuveitis. 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 Avastin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclosporine modified 25 milligram capsules prescribed to treat myasthenia gravis. 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 Cyclosporine modified 25 milligram capsules to treat myasthenia gravis. The approved Medicare compendia state that this medication can, in certain circumstances, be used for your condition. Your provider does not give documentation that these circumstances are met. These circumstances are that 1)you must be resistant to thymectomy, high dose steroids and azathioprine or 2)you still have significant symptoms despite moderate to high dose steroids. A physician reviewed your appeal and determined that the plan is not required to cover Cyclosporine modified 25 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xifaxan prescribed as directed for short gut syndrome. The Part D plan denied your request because the prior authorization criteria were not satisfied. 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 enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. We received some of the documentation requested and included it in our review.At initial coverage determination, a diagnosis of short gut syndrome was given. At the redetermination level, a diagnosis of irritable bowel syndrome with diarrhea was listed on a prescriber statement. The case file did not include medical records to support the change in diagnosis. We requested additional documentation showing why the requested drug was prescribed for the enrollee. The physician returned a statement indicating that the enrollee was prescribed Xifaxan to treat small intestinal bacterial overgrowth in the setting of short gut syndrome and adhesive disease. However, medical records were not provided to support the enrollees diagnosis. It could not be determined whether the requested drug was prescribed for a medically accepted indication.  A physician reviewed your appeal and determined that the plan is not required to cover Xifaxan.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Shingrix Injection for shingles prophylaxis. 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 record shows you have submitted a valid National Drug Code for the Shingrix Injection with the reconsideration request, along with medical records, proof of payment, and a physicians statement. A physician reviewed your appeal and determined that the plan is required to reimburse you for the Shingrix Injection.
Appeal type: Prescription Drug
Decision: Favorable

You requested reimbursement for Oxycodone and Acetaminophen 10-325 milligram tablet prescribed for chronic pain. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. The record shows you were required to pay for your pain medications on April 19, 2021. Your documentation supports you required the pain medication for a tooth ache along with chronic spine and foot pain for which you see Dr. Lubin at a pain clinic.  A physician reviewed your appeal and determined that the plan is required to reimburse the Oxycodone and Acetaminophen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Thymol Crystals. 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 record shows the enrollee was prescribed Thymol in Alcohol 4% Liquid from bulk crystals. Drugs compounded from bulk powders/crystals are not Food and Drug Administration approved and are therefore not covered under Part D. The plan is therefore not required to cover the Thymol Crystals at issue. We determined that the plan is not required to reimburse the Thymol Crystals.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pradaxa 150 milligram capsules prescribed as directed for atrial fibrillation. 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. The medical records show the doctor prescribed Pradaxa to treat atrial fibrillation. 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 your appeal and determined that the plan is not required to cover Pradaxa. 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

You requested Sure-T Paradigm infusion set prescribed for unknown diagnosis. The Part D plan was unable to review your case timely and auto-forwarded 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.Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. If you pay the full cost of a prescription, then you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, you did not provide proof of payment for the drug in the form of a receipt. Therefore, we determined that the plan is not required to reimburse you.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsules prescribed daily for non-24 hour sleep-wake cycle. 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 did not receive the documentation requested.The documentation shows your doctor prescribed Hetlioz to treat non-24 hour sleep-wake cycle. 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 Hetlioz. 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 Oxycontin ER 10 milligram tablets prescribed to treat chronic pain.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 enrollees condition. We also asked for medical records or other documentation to show why this medication was needed. The documentation received was incomplete and supporting medical records were not submitted.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 documentation does 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 Oxycontin ER 10 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine-Prilocaine 2.5%-2.5% cream prescribed as directed. 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 this medication. We did not receive the documentation requested.The documentation does not show why your doctor prescribed Lidocaine-Prilocaine cream. It could not be determined whether the requested drug was prescribed for a medically accepted indication. A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine-Prilocaine cream.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Nexium DR 40 milligram tablet prescribed daily for acid reflux. 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. Your physician states he ordered Nexium DR to treat your acid reflux. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. There must be evidence that you have tried the generic esomeprazole. A physician reviewed your appeal and determined that the plan is required to cover Nexium DR. The physician attestation supports you have tried esomeprazole and it did not provide you any relief. The prior authorization requirements have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Clonazepam 0.5 milligram tablet prescribed for unknown diagnosis. The Part D plan was unable to review your case timely and auto-forwarded 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.Medicare records show that you have Medicare Part D coverage beginning May 1, 2020, with Express Scripts. However, proof of payment in the form of a receipt showing the amount that you paid for the Clonazepam was not provided. According to your plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus your required co-payment amount, and the difference between what the plan normally pays for the drug and what the pharmacy charged you. If you pay the full cost of a prescription, then you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. Therefore, we determined that the plan is not required to reimburse you. Please submit proof of payment to your plan for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Topiramate 25 milligram tablets prescribed as directed for weight gain due to antipsychotic use. 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 initially provided the diagnosis of paranoid schizophrenia.  In the request for reconsideration, the prescriber changed the diagnosis to drug induced obesity, paranoid schizophrenia and genetic torsion dystonia. Records submitted indicate the enrollee was gaining weight due to antipsychotic use for paranoid schizophrenia. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the enrollees condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Topiramate.