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

The enrollee requested Non Stick Pad 3x4 25 ct purchased for the treatment of a wound. The Part D plan denied the request for reimbursement.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 the Non Stick Pad was purchased by the enrollees daughter. According to Medicare rules, drugs and supplies that are considered over-the-counter are excluded from coverage under Part D. Non Stick Pad is an over-the-counter supply. Therefore, we determined that the Part D plan is not required to cover or provide reimbursement for the requested supply.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Silver Sulfadiazine Cream 1% prescribed for unknown diagnosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we 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 the enrollees daughters flexible spending account was used to purchase the Silver Sulfadiazine Cream 1% at the pharmacy. There is no evidence that the insurance information was up-to-date or available to the pharmacy when the Silver Sulfadiazine Cream 1% was purchased. Medicare rules state that plans are not required to reimburse an enrollee for drugs/supplies that were not purchased through the Part D plan. Therefore, the plan is not required to cover or provide reimbursement for Silver Sulfadiazine Cream 1%.To pursue payment, please update your insurance information at the pharmacy where you purchased these drugs and ask to reprocess the claim through your Part D insurance without applying any discounts.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acitretin 25 milligram capsule prescribed for psoriasis The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The medical records show Acitretin was prescribed for treatment of psoriasis. 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 Acitretin. 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: Favorable

At issue is Xolair 150 milligram/milliliter syringe prescribed for chronic idiopathic urticaria. 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 prescriber indicates they prescribed Xolair 150 milligram/milliliter syringe to treat chronic idiopathic urticarial and the enrollee had been symptomatic despite at least two weeks of H1 antihistamine therapy. The prescriber indicates that the enrollee will be taking Zyrtec 10 milligram every day while on Xolair injections. The documentation provided supports the plan's prior authorization requirements were met. A physician reviewed your appeal and determined that the plan is required to cover Xolair 150 milligram/milliliter syringe.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyndamax 61 milligram capsules. The Part D plan denied the appeal request for a tiering exception.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.Vyndamax is on Tier 5 of the plans formulary. This tier is identified as a Specialty Tier. The plan is not required to grant a tiering exception for drugs available on their Specialty Tier. Therefore, a tiering exception cannot be considered.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 Repatha SureClick 140 milligram/milliliter prescribed for homozygous familial hypercholesterolemia. 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 Repatha SureClick 140 milligram/milliliter was prescribed to treat homozygous familial hypercholesterolemia. 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 Repatha SureClick. 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 a request for coverage of Jatenzo 158 milligram oral capsules. The Part D plan denied the request because the drug was not included on the plans formulary and the documentation did not support a formulary 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.The documentation indicates that Jatenzo has been prescribed for the treatment of hypogonadotropic hypogonadism. However, the Medicare approved compendia do not contain any citations to support the use of Jatenzo for the treatment of hypogonadotropic hypogonadism. 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, a formulary exception is 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 Nadolol 20 milligram tablet prescribed for hypertension. 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. Nadolol 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 Livalo 1milligram tablet prescribed for mixed hyperlipidemia. 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. 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 all the 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 Livalo.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ipratropium-Albuterol 0.5-3milligram/3 Ampule prescribed for wheezing and shortness of breath. 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. The records indicate the drug will be used in a nebulizer 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 Ipratropium-Albuterol 5-3milligram/3 Ampule.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Lotemax 0.5% ophthalmic ointment. 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 Lotemax 0.5% ophthalmic ointment has been prescribed for the treatment of neurotrophic keratoconjunctivitis of both eyes, symblepharon of both eyes, and bilateral keratoconjunctivitis sicca. However, the Medicare approved compendia do not contain any citations to support the use of Lotemax ointment for the treatment of the noted conditions. Therefore, the drug is being prescribed for non-medically accepted indications 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

You requested Xerese cream 5;1 percent prescribed as directed for zoster without complications. 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. The documentation shows your doctor prescribed Xerese cream to treat your zoster without complications. 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 Xerese cream.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Ubrelvy 100 milligram tablets prescribed for the treatment of migraines. 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. Ubrelvy 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. 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 Pyridostigmine Bromide 60 milligram tablets. The Part D plan denied the appeal request for a tiering exception.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.Pyridostigmine Bromide is a generic drug on Tier 3 of the plans formulary. There are no generic 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

You requested prior authorization for Pregabalin 75 milligram capsules prescribed as directed for 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 information submitted at the reconsideration level. The documentation shows your doctor prescribed Pregabalin to treat your pain, not related to the management of fibromyalgia or management of neuropathic pain associated with spinal cord injury, post herpetic neuralgia, neuropathic pain associated with diabetic peripheral neuropathy, cancer treatment related neuropathic pain or cancer treatment related neuropathic pain. 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 Pregabalin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pennsaid 2% solution. 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 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 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 Armour Thyroid 30 milligram tablet to treat hypothyroidism. 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.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 Chantix Starting Month Box 53/28 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. Chantix Starting Month Box is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Orgovyx 120 milligram tablets prescribed for the treatment of unfavorable intermediate risk prostate cancer. The Part D plan denied the request stating 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 prescriber notes that the enrollee will be given androgen deprivation therapy with Orgovyx in addition to external beam radiation therapy. As outlined in the National Comprehensive Cancer Network (NCCN) guidelines, it is a category 2A recommendation for Orgovyx to be used as androgen deprivation therapy with external beam radiation therapy in the treatment of unfavorable intermediate risk prostate cancer. Therefore, the drug is being prescribed for a medically accepted indication as outlined in the NCCN guidelines.The plans prior authorization requirement for coverage of the drug is that it is to be used for a medically accepted indication. The plan has no step therapy or quantity limit requirements for the requested drug. Therefore, since the NCCN guidelines support that the drug is being used for a medically accepted indication, coverage for the drug can be allowed. A physician reviewed the appeal and determined that the plan is required to cover the Orgovyx in this case.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20 milligram capsules prescribed to treat non-24-hour sleep wake disorder. 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 the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. We did not receive the requested documentation.The appeal request is for Hetlioz 20 milligram capsules to treat non-24-hour sleep wake disorder. The enrollees 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 Hetlioz 20 milligram capsules, as the plans prior authorization requirements has not been satisfied. 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 Cevimeline Hydrochloride 30-milligram capsule to treat xerostomia due to graft versus host 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.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 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 reimbursement request for Shingrix vaccine. 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 record shows the enrollee received the Shingrix vaccine at the prescribers office. According to the plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus the enrollees required co-payment amount, and the difference between what the plan normally pays for the drug and what the enrollee was charged. If the enrollee pays the full cost of a prescription, then the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, the enrollee did not provide proof of payment for the vaccine in the form of a receipt. Therefore, we determined that the plan is not required to reimburse the vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Estradiol Cream 0.01%. 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 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. Estradiol Cream 0.01% is a generic drug on Tier 3 of the plans formulary. There are no generic drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a reimbursement request for Colchicine 0.6 milligram tablets prescribed for acute pericarditis. 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.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 the enrollee. A physician reviewed the appeal and determined that the plan is not required to reimburse Colchicine.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Mavyret (Glecaprevir 100 milligrams/ Pibrentasvir 40 milligrams) tablets, 84 tablets per 28 days. The Part D plan denied the request stating that 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 prescriber is requesting an 8-week course of Mavyret for a hepatitis C virus-negative recipient who is to receive a deceased donor kidney transplant from a hepatitis C virus-positive donor. The American Association for the Study of Liver Diseases (AASLD) does include guidelines that support the use of prophylactic/preemptive direct-acting antiviral therapy with Mavyret for hepatitis C virus-negative recipients of a non-liver allograft/transplant from a hepatitis C virus-positive donor. The AASLD recommendation is a daily fixed-dose combination of Glecaprevir (300 milligrams)/Pibrentasvir (120 milligrams) for a course of 8 weeks, which is what has been ordered by the prescriber. Therefore, the submitted medical records support that Mavyret is being prescribed for a medically accepted indication as outlined in the AASLD. A physician reviewed the appeal and determined that the plan is required to cover the Mavyret.