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

At issue is Emgality 120 milligram per milliliter pen injector. 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. Emgality 120 milligram per milliliter pen injector is a biological product drug on Tier 4 of the plans formulary. There are no biological product 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 request for coverage of sterile water for injection. 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.Sterile water for injection does not meet the definition of a Part D drug. Therefore, the sterile water is not eligible for coverage under Medicare Part D. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligram tablet prescribed at an unknown frequency for irritable bowel syndrome with diarrhea. 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 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 documentation requested.The request states the doctor prescribed Xifaxan to treat the enrollees irritable bowel syndrome with diarrhea. 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 Xifaxan. There are no medical records to determine if the enrollee meets the prior authorization requirements of the plan. 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 tiering exception request for Ubrelvy 100 milligram tablets prescribed for the Enrollees condition. 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.Ubrelvy 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 the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Otezla 30 milligram tablets 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. 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 a quantity limit exception for Lidocaine-Prilocaine 2.5%-2.5% cream prescribed for the enrollees condition. 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 documentation indicates the plan has approved the drug for a quantity of 30 grams per 30 days. The enrollee has requested a quantity of 90 grams per 90 days. The documentation submitted did not include a supporting statement. A request was sent to the prescriber; however, no further documentation was received. 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 Lidocaine-Prilocaine cream for a quantity limit exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Chlorzoxazone 500 milligram oral tablet prescribed daily for muscle spasms, mid-line low back pain, and unspecified convulsions. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Chlorzoxazone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 10 milligram tablet prescribed daily for insomnia. 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 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 neeed. We did not receive the documentation requested.The doctor prescribed Zolpidem Tartrate to treat the enrollees insomnia. 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 Zolpidem Tartrate. 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 Diclofenac Sodium 1% gel prescribed daily for osteoarthritis of the shoulder joints. 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 Diclofenac Sodium gel to treat your osteoarthritis of the shoulder joints. 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 Diclofenac Sodium 1% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 1.62% gel prescribed for erectile dysfunction. 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 Testosterone because it was prescribed to treat erectile dysfunction. Drugs prescribed for the treatment of sexual or erectile dysfunction 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tretinoin 0.05% cream prescribed for calcinosis cutis and osteoma cutis. 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 Tretinoin 0.05% cream was prescribed for calcinosis cutis and osteoma cutis. The Medicare approved compendia do not support the use of Tretinoin for calcinosis cutis. In addition, the drug has not been approved by the Food and Drug administration for treatment of osteoma cutis.A physician reviewed your appeal and determined that the plan is not required to cover Tretinoin.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Acterma 80 milligram/4-milliliter solution prescribed monthly for giant cell arteritis. 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 Acterma to treat the Enrollees giant cell arteritis. Medical records support the type of giant cell arteritis in this Enrollee is temporal arteritis that was biopsy proven. Therefore, this drug is being used for a medically accepted indication.A physician reviewed the appeal and determined that the plan is required to cover Acterma.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate Mofetil 500 milligram tablet prescribed two tablets twice daily for dermatopolymyositis. 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 Mycophenolate Mofetil to treat the Enrollees dermatopolymyositis. However, the Medicare approved compendia do not support the use of Mycophenolate Mofetil for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nurtec ODT 75 milligram oral tablet prescribed daily for other migraine, not intractable, with status migrainosus. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the documentation does not support why all 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 Nurtec ODT.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate extended-release 54 milligram oral tablet prescribed 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 or other documentation 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. However, we did not receive the documentation.You requested Methylphenidate oral tablet for the provided diagnosis of attention deficit hyperactivity disorder. However, no medical records have been submitted for review to support the noted condition. Therefore, it cannot be determined if the requested drug was prescribed for a medically accepted indication. The formulary exception was not addressed because 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 Methylphenidate.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollee requested compounded drug Trimix #4 prescribed for erectile dysfunction. The 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.According to Medicare rules, drugs that fall into the category of bulk powders are excluded from coverage under Part D. The ingredient Phentolamine Mesaylate powder does not meet the definition of a Part D drug. The ingredients Papaverin HCL powder and Alprostadil powder are drugs used to treat erectile dysfunction and are excluded from coverage under Medicare Part D. In addition, Medicare Part D does not cover non-prescription drugs. We reviewed Food and Drug Administration (FDA)-approved sources for the drugs classification or determined from other available resources that the drugs are non-prescription or over-the-counter (OTC) drugs. Therefore, the ingredients Ethyl Alcohol 100% liquid, Sodium Chloride granules, and Bacteriostatic water are not eligible for Part D coverage. Therefore, we determined that the plan is not required to cover the Trimix #4 compound. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollee requested Atorvastatin 40 milligram tablet prescribed for unknown diagnosis. 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. The record shows the Enrollee purchased drugs from a pharmacy outside of the United States. We determined that the plan is not required to cover or reimburse the Enrollee for Atorvastatin because it was purchased in Canada. Drugs purchased outside of the United States are excluded from coverage. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollee requested Metoprolol 50 milligram tablet prescribed for unknown diagnosis. 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. The record shows the Enrollee purchased drugs from a pharmacy outside of the United States. We determined that the plan is not required to cover or reimburse the Enrollee for Metoprolol because it was purchased in Canada. Drugs purchased outside of the United States are excluded from coverage. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollee requested Myrbetriq 50 milligram tablet prescribed for unknown diagnosis. 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. The record shows the Enrollee purchased drugs from a pharmacy outside of the United States. We determined that the plan is not required to cover or reimburse the Enrollee for Myrbetriq because it was purchased in Canada. Drugs purchased outside of the United States are excluded from coverage. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Copaxone 20 milligram subcutaneous injection prescribed daily. 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. This drug is included 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 Loteprednol Etabonate 0.5% eye drop prescribed for primary open-angle glaucoma. 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. We also asked for medical records or other documentation to show why the medication is needed. 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. 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. A physician reviewed your appeal and determined that the plan is not required to cover Loteprednol Etabonate.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Mycophenolate Mofetil 250 milligram capsules prescribed for renal transplant rejection prophylaxis. The Part D plan denied the request stating that the enrollees transplant was covered by Medicare; therefore, coverage for the requested drug would be available under Medicare Part B.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 also researched Medicare systems and reviewed the enrollment data available.The Medicare Health Insurance Master Record (HIMR) system does not show that the enrollee received a Medicare-covered transplant. Therefore, since the records support that the enrollees transplant was not covered by Medicare, coverage of the requested drug would be available under the Part D plan. However, Part D sponsors are responsible for ensuring that a covered Part D drug is being prescribed for a medically accepted indication. As outlined in the Medicare approved compendia, the use of Mycophenolate Mofetil for renal transplant rejection prophylaxis is an acceptable use when the drug is being used in combination with other immunosuppressant medications. During this review, a prescriber statement and medical records were requested from the prescribers and the prescriber submitted the requested documentation. The prescriber has noted that the enrollee is currently taking Envarsus and Prednisone in addition to the Mycophenolate Mofetil. The submitted progress notes validate this statement. Therefore, the newly submitted documentation validates that the drug is being prescribed for a medically accepted indication. The only requirements for coverage of Mycophenolate Mofetil included in the plan to ensure that coverage would not be available under Medicare Part B and to ensure the medication is being used for a medically accepted indication. As noted previously, HIMR does not indicate that the enrollee received a Medicare-covered transplant and the documentation supports that the medication is being prescribed for a medically accepted indication.  As such, the requested drug is eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollee requested Bacitracin 500 unit/gram ointment. 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.The record shows the Enrollee received Bacitracin as a self-administered drug in the hospital emergency room. According to Medicare rules, drugs that are considered over-the-counter are excluded from coverage under Part D. Bacitracin is on Medicares excluded list of drugs because it is an over-the-counter medication. Therefore, we determined that the Part D plan is not required to cover or reimburse the Enrollee for Bacitracin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Semglee 100 units/milliliter vial prescribed as directed for the enrollees condition. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, there are no medical records submitted to 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 Semglee.