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

At issue is Dupixent Solution 300 milligram/2 milliliter pre-filled syringe prescribed for moderate to severe atopic dermatitis. 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 records submitted at the reconsideration level. Your prescriber indicates that they prescribed Dupixent Solution 300 milligram/2 milliliter is prescribed for moderate to severe dermatitis. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation was not provided to show the enrollee tried or had an intolerance to a topical calcineurin inhibitor. The plan's coverage criteria has not been met.  A physician reviewed your 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 Dupixent Solution 300 milligram/2 milliliter prefilled syringe prescribed for atopic dermatitis, unspecified. 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. The documentation, however, does not satisfy the plans non-formulary exception criteria. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary alternatives required by the plan, to treat this condition, would likely not be as effective as the requested drug, and/or would likely cause adverse reaction(s) or other harm. The tiering exception request is not further considered.A physician reviewed your appeal and determined that the plan is not required to cover Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Bystolic 20 milligram tablet prescribed once daily. 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. We asked your prescriber to send us information about 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 similar medications on the lower tiers would not work for you.  However, we did not receive the documentation.Bystolic is a brand drug on Tier 4 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

You requested Diclofenac Sodium 3% gel prescribed for unilateral primary osteoarthritis of the left knee. 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 enrollee's condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. However, we did not receive the documentation.The documentation shows Diclofenac Sodium 3% gel was prescribed to treat unilateral primary osteoarthritis of the left knee However, the Medicare approved compendia do not support the use of this drug for the enrollee's condition. A physician reviewed your appeal and determined that the plan is not required to cover Diclofenac Sodium 3% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Retacrit 20,000-units/milliliter to treat anemia associated with chronic kidney 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 documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records.  A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate ER 12.5 milligram tablet prescribed to treat insomnia. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We asked 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 documentation shows Zolpidem Tartrate ER was prescribed to treat 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 your appeal and determined that the plan is not required to cover Zolpidem Tartrate ER. 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 Lidocaine 5 percent patch prescribed as directed for persistent lower back 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 Lidocaine to treat your persistent lower back pain. However, the Medicare approved compendia do not support the use of this drug for your condition. It is unclear where you are to apply the patch, how long your pain has been going on, and the intensity of the pain.A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Xiidra 5% ophthalmic dropperette prescribed for keratoconjunctivitis sicca. 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. (It is noted that paperwork for patient financial assistance has been submitted at reconsideration; however, we are an independent review entity that does second level appeal reviews for Part D plan denials. We do not process forms for financial assistance. Please submit the paperwork to the correct organization/program).Xiidra has been approved 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 the appeal and determined that the plan is not required to grant a lower-cost tiering exception for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a compound intravenous medication consisting of Mycamine 100 milligram vial and Sodium Chloride prescribed for osteomyelitis, unspecified. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.For a compound item to be approved, all ingredients that are Part D drugs must be shown as being used for a medically accepted indication and route of drug must be supported by Medicare approved compendia. Sodium Chloride is able to be approved as requested. However, Medicare approve compendia do not support Mycamine 100 milligram for osteomyelitis, unspecified as a medically accepted indication. We were unable to obtain additional information. Mycamine is not eligible for Part D coverage. A physician reviewed your appeal and determined that the plan is not required to cover Mycamine 100 milligram vial.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Saxenda 18 milligrams per 3 milliliters pen injector prescribed to treat severe obesity. 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 information submitted at the reconsideration level.The documentation shows the enrollee was prescribed Saxenda 18 milligrams per 3 milliliters pen injector to treat severe obesity. We determined the plan is not required to cover Saxenda because it is excluded from coverage under Part D. 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 Forteo Solution 620-micrograms/2.48-milliliters Pen-Injector to treat age-related osteoporosis with current pathological fracture, unspecified femur. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.Your medical records show your doctor prescribed Forteo to treat your age-related osteoporosis with current pathological fracture, unspecified femur. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Incruse Ellipta 62.5 microgram inhalation aerosol powder 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. Incruse Ellipta 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 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 Lidocaine 5% Patch to treat low back 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 your prescriber to send us a prescriber statement, answers to prior authorization coverage criteria, and medical records. However, we did not receive the documentation.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: Favorable

 At issue Forteo pen-injector 620 microgram/4.48 milliliter prescribed for osteoporosis. 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 regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. We received the documentation and included it in our review.The plan requires for coverage of Forteo that the enrollee have a pre-treatment T-score of less than or equal to -2.5 or pre-treatment T-score greater than -2.5 and less than -1 with a high pre-treatment Fracture Risk Assessment Tool (FRAX) fracture probability. In addition, the enrollee has failed prior treatment with or is intolerant to a previous injectable osteoporosis therapy. The documentation includes clinical notes which satisfied the plan's coverage criteria. A physician reviewed the appeal and determined that Forteo is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ingrezza 40-milligram capsule to treat tardive dyskinesia. 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 your prescriber to send us a prescriber statement, answers to prior authorization coverage criteria/quantity limit exception, and medical records. However, we did not receive the documentation.Your medical records show your doctor prescribed Ingrezza to treat your tardive dyskinesia. At reconsideration, no medical records were provided by the prescriber to support this diagnosis. The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria, with supporting medical records, and/or the coverage criteria are not satisfied by the provided documentation.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 Horizant ER 300 milligram tablets prescribed as directed for neuralgia and neuritis, unspecified and nerve pain. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication.  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.The use of the requested drug to treat the provided diagnosis is an off-label use.  The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Horizant ER.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Testosterone 1.62% gel pump prescribed for hypogonadism. The Part D plan denied the request for coverage because the plans prior authorization requirements were not met.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. At reconsideration, the prescriber has submitted laboratory results for low testosterone levels obtained on two separate days. However, no other documentation has been submitted. During this review, a request was submitted to the prescriber to clarify the enrollees diagnosis and to provide supporting medical records. The prescriber did not submit the requested documentation.The available documentation indicates that the enrollee has hypogonadism. However, there is no indication whether the enrollee has primary hypogonadism, hypogonadotropic hypogonadism, or age-related (late-onset) hypogonadism. As outlined in the Medicare approved compendia, the safety and efficacy of testosterone replacement therapy in men with low testosterone concentrations related to aging have not been established. Therefore, the use of Testosterone in age-related (late-onset) hypogonadism is not a medically accepted indication. As such, there is insufficient documentation to support that the requested drug is being prescribed for a medically accepted indication and the drug 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

At issue is Silodosin 8 milligram capsules prescribed as directed for benign prostatic hyperplasia without urinary obstruction and overactive bladder. 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 Silodosin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Estradiol 0.0375-micromgram/24-Hour Patch Twice Weekly to treat menopausal and female climacteric states. 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.Estradiol patch is a generic drug on Tier 3 of the plans formulary. There are no generic drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Diclofenac Epolamine 1.3% topical patches. The Part D plan denied the request for coverage because the medication was being used 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 diagnosis initially provided by the prescriber to the Part D plan is osteoarthritis of the knees. However, the Medicare approved compendia do not contain any citations to support the use of Diclofenac Epolamine 1.3% topical patches for the treatment of this condition.At reconsideration, the prescriber has stated that the enrollee also has pain due to back strain. However, no medical records have been submitted to validate this additional diagnosis. Therefore, there is insufficient documentation to determine if the requested drug is being prescribed for a medically accepted indication. As such, the requested drug 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

At issue is Sucralfate 1 gram/10 milliliter suspension prescribed for the enrollees condition. The Part D plan denied the request.We received a 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. According to the plan's Evidence of Coverage, if the 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. The documentation submitted does not include a receipt showing the enrollee paid for the Sucralfate. We determined that the plan is not required to reimburse the enrollee for their share of the cost.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Forteo 620 microgram/2.48 milliliter pen injector prescribed 20 micrograms daily to treat age related osteoporosis. 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.  On the prior authorization request form dated 7/26/2021 and signed by the prescriber, the prescriber wrote the request as, '12 pens per 28 days.'  Since each pen has 1 ml this is asking for 12 mls per 28 days.  The plan denied this appeal as far in excess of the standard dosing.  In the reconsideration appeal the prescriber clarified the requested dose as one pen per 28 days.The plan limits the amount of Forteo to 2.48 milliliters per 28 days. The requested quantity is within the plans allowed quantity limit. Our physician reviewer's opinion is that quantity limit criteria are met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Epolamine 1.3% Patch to treat low back pain, cervical disc disorder, unspecified region, other intervertebral disc degeneration, lumbar region, and other muscle spasm. 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 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.