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

At issue is Lidocaine 5 percent ointment to treat neck pain due to tics from Tourette's. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including 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 diagnosis. Therefore, the requested drug(s) 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: Favorable

At issue is Epclusa 400-100-milligram tablet to treat chronic viral hepatitis C, genotype 3, without cirrhosis. 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.Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Apidra injection 100 units prescribed for the treatment of type 2 diabetes. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The submitted documentation shows the requested drug is being administered through an external infusion pump in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover the requested drug. 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 Opsumit 10-milligram tablet to treat chronic thromboembolic pulmonary hypertension. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The requested drug is not on the plans formulary. 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 alternative drugs provided on the plans formulary list would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm.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 Lidocaine Prilocaine cream prescribed daily for the treatment of end stage renal disease.We received the case to perform an independent and de novo review. To make our decision, we reviewed 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. According to Medicare rules, the requested drug cannot be approved for separate payment under Part D when it is for treatment on a patient who is receiving dialysis. Medicare records show the enrollee is actively receiving dialysis. Therefore, the requested drug must be billed by the renal dialysis facility.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xgeva 120-milligram per 1.7-milliliter solution  to treat multiple myeloma. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria.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 Glyburide 1.25-milligram tablet to treat type 2 diabetes mellitus. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the enrollee has satisfied the plans prior authorization coverage criteria.  However, we did not receive the requested information.  The submitted documentation does not satisfy the plans coverage criteria.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 Febuxostat 40-milligram tablets to treat gout. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The requested drug is not on the plans formulary. In order to grant an exception for a drug not on the plans formulary, all alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the documentation does not sufficiently address why the alternative drugs provided on the plans formulary list would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm.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 Testosterone 1 percent gel packets to treat 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 reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.We requested additional information from the prescriber. Specifically, we requested a valid prescribers statement and documentation confirming the diagnosis related to the requested drug. We also requested documentation indicating that the enrollee has satisfied the plans prior authorization coverage criteria. However, we did not receive the requested information.Without the requested information, we cannot establish that the requested drug is medically necessary. Therefore, the requested drug is not eligible for coverage under Medicare Part D. In addition, the plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The documentation does not satisfy the plans coverage criteria.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 Mesalamine 1.2-gram DR tablets to treat gastro-esophageal reflux disease without esophagitis. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including 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 diagnosis. Therefore, the requested drug(s) 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 Testosterone 1.62 percent gel prescribed for hypogonadotropic hypogonadism and resultant testosterone deficiency. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the enrollee has satisfied the plans prior authorization coverage criteria. We received additional documentation and included it in the review.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Epclusa 400-100-milligram tablets to treat chronic hepatitis C. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The documentation provided now satisfies all of the the plans coverage criteria. Documentation of Hepatitis B status from October 12, 2021, was submitted.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hetlioz 20-milligrams capsule to treat circadian rhythm sleep disorder and a sleep-wake disorder. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.We requested additional information from the prescriber. Specifically, we requested documentation supporting if the enrollee has satisfied the diagnostic criteria for non-24 hour sleep-wake cycle. We also requested documentation indicating that the enrollee has satisfied the plans prior authorization coverage criteria. However, we did not receive the requested information.Without the requested information, we are not able to determine whether the requested drug has been prescribed for a medically accepted indication. In addition, the plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The documentation does not satisfy the plans coverage criteria. 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 Dupixent 300-milligrams/2-milliliters Syringe to treat bullous 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 use of the requested drug to treat the provided diagnosis is supported by the Medicare approved compendia. 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 why other drugs on the plans formulary would not work for you.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 Buprenorphine HCL 75-milliequivalent to treat spinal stenosis of lumbar region with neurogenic claudication. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria.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 Breo Ellipta 200-25 microgram inhaler to treat the enrollee's condition. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.A request was submitted to the prescriber to provide a diagnosis for the requested drug. However, a reply from the prescriber was not received. Without the requested information, we cannot establish that the requested drug is medically necessary. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the enrollees appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a reimbursement request for Clonazepam 0.5-milligram tablet to treat the enrollee's condition. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.A request was submitted to the prescriber to provide a diagnosis for the requested drug. However, a reply from the prescriber was not received. Without the requested information, we cannot establish that the requested drug is medically necessary. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the enrollees appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a reimbursement request for Combivent 20-100-microgram actuation inhahler to treat the enrollee's condition. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.A request was submitted to the prescriber to provide a diagnosis for the requested drug. However, a reply from the prescriber was not received. Without the requested information, we cannot establish that the requested drug is medically necessary. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the enrollees appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a reimbursement request for Levothyroxine 75-microgram tablet to treat the enrollee's condition. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.A request was submitted to the prescriber to provide a diagnosis for the requested drug. However, a reply from the prescriber was not received. Without the requested information, we cannot establish that the requested drug is medically necessary. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the enrollees appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a reimbursement request for Lorazepam 1-milligram tablet to treat the enrollee's condition. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.A request was submitted to the prescriber to provide a diagnosis for the requested drug. However, a reply from the prescriber was not received. Without the requested information, we cannot establish that the requested drug is medically necessary. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the enrollees appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a reimbursement request for Simvastatin to treat the enrollee's condition. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.A request was submitted to the prescriber to provide a diagnosis for the requested drug. However, a reply from the prescriber was not received. Without the requested information, we cannot establish that the requested drug is medically necessary. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the enrollees appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a reimbursement request for Sulfasalazine 500-milligram tablet to treat the enrollee's condition. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.A request was submitted to the prescriber to provide a diagnosis for the requested drug. However, a reply from the prescriber was not received. Without the requested information, we cannot establish that the requested drug is medically necessary. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the enrollees appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aspirin 51-milligram tablet 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 reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage. There is no evidence the plan provides supplemental coverage for this drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Loratadine 10-milligram tablet 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 reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage. There is no evidence the plan provides supplemental coverage for this drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Euflexxa 20-milligram/2-milliliter injection to treat knee 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 reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs that are not approved by the Food and Drug Administration (FDA) are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine Hydrochloride 8-milligram tablet Sublingual 120-tablets/30-days to treat opioid dependence, in remission. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The plan limits the amount of Buprenorphine Hydrochloride 8-milligram tablet sublingual to 90-tablets/30-days.  The prescriber is requesting 32 mg per day.  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.  The drug label available at Drugs@FDA.gov states, 'The recommended target dosage of SUBUTEX is 16 mg as a single daily dose. Dosages higher than 24 mg have not been demonstrated to provide any clinical advantage.'  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 Testosterone 1.62-percent gel pump to treat late-onset (age-related) 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 reviewed all documentation submitted including 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 diagnosis. Per the compendia, The safety and efficacy of testosterone therapy have not been established in men with late-onset (age-related) hypogonadism. 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.