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

At issue is Tremfya 100 milligram/milliliter injector prescribed for psoriatic arthritis. 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 biologic not on the plans formulary, alternative formulary biologics must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other biologics 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 Tremfya.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armour Thyroid 15 milligram tablets prescribed for the enrollees condition. The Part D plan denied the 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.The drug at issue is not Food and Drug Administration approved. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. 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 Sildenafil 20 milligram tablet prescribed three times daily for pulmonary hypertension with congestive heart failure. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows the doctor prescribed Sildenafil to treat the enrollees pulmonary hypertension with congestive heart failure. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Sildenafil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550-milligram tablet. At initial determination and redetermination the diagnosis of irritable bowel syndrome with constipation was given. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.At reconsideration the diagnoses gas pain, abdominal distension, and irritable bowel syndrome with constipation were given. However, the Medicare approved compendia do not support the use of this drug for your conditions. 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 quantity limit exception for Elmiron 100 milligram capsules. 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 indicates the drug at issue was prescribed for chronic cystitis. The prescriber requested 200 capsules for a 66-day supply. The drug at issue is a specialty drug that can only be allowed for a 30-day supply. Therefore, a quantity limit exception cannot be granted and the amount approved by the plan is upheld.Therefore, the plan is not required to cover Elmiron for a quantity limit exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rytary 36.25-145 milligram capsules prescribed for the enrollees condition. The Part D plan denied the 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.Rytary 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 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 Lidocaine 5% Patch to treat other chronic pain and muscle spasm of back. 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 Nurtec 75 milligram oral disintegrating tablets to treat migraine headaches. 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 prescriber indicates that several of plans alternative formulary drugs were tried and failed or could cause harm. 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 records do not support why all 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 Nurtec 75 milligram oral disintegrating tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium gel 1% prescribed for hip and neck 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 Diclofenac Sodium was prescribed for hip and neck pain. 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 Diclofenac Sodium.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Piqray 300 milligram daily dose prescribed for PIK3CA mutation and single pulmonary nodule. 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 Piqray was prescribed for treatment of PIK3CA mutation and single pulmonary nodule. 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 Piqray.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Guanfacine Hydrochloride 1-milligram Immediate Release tablet to treat frontal love and executive function deficit. 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 shows your doctor prescribed Guanfacine to treat your condition. However, the Medicare approved compendia do not support the use of this drug for your 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 initial determination and redetermination, Jadenu 360 milligram tablet prescribed for an unknown diagnosis. The Part D plan denied your request because the requested drug is not on the plans formulary. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked the prescriber to send us information regarding the enrollees condition. We did receive the documentation requested.At reconsideration medical records indicate that this patient has myelodysplastic syndrome with iron overload. Review of compendia references support this as a medically accepted indication. This medication is not on your plan's list of medications. The prescriber has not given a clear medical reason why all medications required by the plan, on that list, did not work for you. This reason has to be in the medical record with details of when you tried those medications. The reason the medications on the formulary won't work or could cause you harm have to be stated. Why the other medications required by the plan will not work must be discussed. Therefore, an exception to the plans formulary coverage criteria is not supported. 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 Tramadol 50-milligram tablet to treat low back pain and chronic neck pain. 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 related to the enrollees hospice care and end-of-life care, medical records, and medications previously prescribed for your conditions. We did not receive the requested information.Drugs used for hospice care must be sent to Medicare Part A. Only drugs for health issues not related to end-of-life care can be covered under Medicare Part D while you are on hospice. 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 Indomethacin 50 milligram suppository prescribed for an unknown diagnosis. The Part D plan denied your request because Indomethacin is not on the plans formulary.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked your prescriber to send us information regarding the enrollees 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.. However, we did not receive the documentation.. Without a diagnosis it cannot be established that Indomethacin 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, Indomethacin is not eligible for coverage under Medicare Part D. Furthermore, 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 Indomethacin.
Appeal type: Prescription Drug
Decision: Favorable

The enrollee requested Magic Mouthwash 120 milliliter prescribed for pain control related to malignant neoplasm of labium majus.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows the enrollee purchased the Magic Mouthwash from a compounding pharmacy on June 7, 2021. The plan provided documentation showing the drug would be approved for coverage. According to the plan's Evidence of Coverage, if an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. The documentation submitted includes a receipt showing the enrollee paid for the Magic Mouthwash at full cost. Therefore, we determined that the plan is required to provide reimbursement for their share of the cost of the Magic Mouthwash to the enrollee.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Subsys 100 micrgram spray prescribed for pain associated with throat cancer. The Part D plan denied the enrollees 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 determined that the plan is not required to cover the Subsys spray. Medicare does not allow Part D drug plans to cover drugs produced by a manufacturer that does not participate in the Medicare Gap Discount Program. The Center for Medicare and Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. Records show that the manufacturer, Insys Therapeutics, did not sign the agreement and does not participate in the Medicare Gap Discount Program. Therefore, the Part D plan is not required to cover the Subsys spray. 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 Lidocaine 5% patch prescribed daily for unspecified pain. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows the doctor prescribed Lidocaine 5% patch to treat the enrollees pain. The prescriber states the enrollees pain is not associated with post-herpetic neuralgia, diabetic neuropathy, or cancer-related neuropathy. The Medicare approved compendia do not support the use of this drug for this unspecified condition. A physician reviewed the appeal and determined that the plan is not required to cover Lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil 20 milligram tablets prescribed for other secondary pulmonary hypertension. 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 submitted documentation indicates the prescriber ordered Sildenafil for other secondary pulmonary hypertension. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.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 Jornay PM 20-milligram capsule to treat narcolepsy with cataplexy. The Part D plan denied the request. The requested drug is not on the plans formulary. 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.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.Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entyvio 300-milligram IV infusion. 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 also researched Medicare systems and reviewed the enrollment data available.The record shows that the enrollee is not receiving the Entyvio IV infusion at home or in a long-term care facility. When a drug is not being administered in a long-term care facility nor at home, the drug is not covered under 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 per 2 milliliter syringe prescribed 600 milligrams day one and then 300 milligrams every two weeks for moderate to severe asthma. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.The doctor prescribed Dupixent to treat the enrollees moderate to severe asthma. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed the appeal and determined that the plan is not required to cover Dupixent. 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 Zolpidem Tartrate 10 milligram tablet prescribed for anoxic brain damage. 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 Zolpidem Tartrate was prescribed for anoxic brain damage. 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 Zolpidem Tartrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ondansetron Hydrochloride 4 milligram tablets prescribed to treat abnormal weight loss, decreased appetite, and nausea. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows the doctor prescribed Ondansetron Hydrochloride 4 milligram tablets to treat abnormal weight loss, decreased appetite and nausea. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed the appeal and determined that the plan is not required to cover Ondansetron Hydrochloride 4 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Farxiga 10 milligram tablets. 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.Farxiga 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 Hetlioz 20-milligram capsule to treat non-24-hour sleep-wake disorder. The 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.To support this diagnosis, the prescriber provided no medical records. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Saxenda 18 milligram/3 milliliter solution prescribed for type 2 diabetes mellitus with hyperglycemia. 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 determined that the plan is not required to cover Saxenda because it is a drug indicated for weight loss. Drugs to treat anorexia, weight loss, or weight gain are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. 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.