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

At issue is a request for coverage of Olumiant 2 milligram tablets prescribed for rheumatoid 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 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.Olumiant is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary alternatives included in the plan to treat the noted condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nuedexta 20-10 milligram capsules prescribed daily for pseudobulbar affect. 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.Your medical records show your doctor prescribed Nuedexta to treat your pseudobulbar affect. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation does not satisfy the plans coverage criteria because a diagnosis of amyotrophic lateral sclerosis or multiple sclerosis is not documented. A physician reviewed your appeal and determined that the plan is not required to cover Nuedexta. 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 Xeljanz 5 milligram tablet prescribed for alopecia universalis. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested. The documentation shows your doctor prescribed Xeljanz to treat your alopecia universalis. 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 Xeljanz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrocodone-Acetaminophen 5-325 milligram tablets prescribed for cellulitis and abscess of the mouth.  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 establish medical necessity and confirm that the requested drug is being used for a medically accepted indication, as required by Medicare, medical records supporting a medically accepted indication are required. These records were requested from the prescriber, and we did not receive information that could answer these medical necessity issues.  A physician reviewed your appeal and determined that the plan is not required to cover Hydrocodone-Acetaminophen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fentanyl 100-microgram Patch TD72. At initial determination and redetermination no diagnosis 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 of generalized osteoarthritis (M15.9), status post hip replacement (Z96.649), diffuse myofascial pain syndrome (M79.18), generalized muscle ache (M79.10), lumbar stenosis with neurogenic claudication (M48.062), degenerative arthritis of cervical spine (M47.812), hypogonadism in male (E29.1), chronic pain of multiple joints (M25.50), tobacco consumption (Z72.0), and spondylosis of thoracolumbar region without myelopathy or radiculopathy (M47.815) were given. The documentation provided addressed the plans coverage criteria, and those criteria were not satisfied. 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 request for coverage of Zolpidem 10 milligram tablets. The Part D plan denied the request for coverage because the drug was being prescribed for a non-medically accepted indication.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation originally submitted to the plan indicates that Zolpidem has been prescribed for sleeping difficulty caused by generalized anxiety disorder, bipolar disorder, and attention deficit hyperactive disorder. It is also noted that the enrollee has been taking Zolpidem for this condition for years. However, the Medicare approved compendia do not contain any citations to support the use of Zolpidem for the treatment of sleeping difficulty caused by other conditions.At reconsideration, an additional diagnosis has been added. This diagnosis is listed as other insomnia not due to a substance or known physiological condition. However, while the submitted progress notes support the diagnoses of generalized anxiety disorder, bipolar disorder, and attention deficit hyperactive disorder, they do not support the newly added diagnosis of insomnia. Therefore, the medical records do not support that the Zolpidem is being prescribed for a medically accepted indication. A physician reviewed the appeal and determined that the plan is not required to cover the Zolpidem.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tacrolimus 0.1% Cream to treat localized scleroderma morphea. 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.Non-Food and Drug Administration approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.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 ODT 75 milligram disintegrating tablet prescribed for migraines. The Part D plan did not make a decision.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.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 was 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 the appeal and determined that the plan is not required to cover Nurtec ODT.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Buprenorphine Hydrochloride 2 milligram sublingual tablets. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that Buprenorphine Hydrochloride sublingual tablets have been prescribed for the treatment of chronic pain syndrome due to the presence of multiple chronic musculoskeletal conditions. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the Buprenorphine Hydrochloride sublingual tablets.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Votrient 200 milligram tablet prescribed for metastatic synovial sarcoma. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. The medical records show you prescribed Votrient 200 milligram tablet to treat the enrollees metastatic synovial sarcoma. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The medical records indicate that the enrollee received prior ifosfamide chemotherapy; therefore, the enrollee has a Food & Drug Administration approved indication for the medication in question. An oncologist reviewed your appeal and determined that the plan is required to cover Votrient 200 milligram tablet as an exception to the plans prior authorization requirements.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vraylar 1.5 milligram capsule prescribed daily for major depressive 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 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 this medication was needed. We did not receive the documentation requested.At reconsideration a diagnosis of bipolar disorder was given. No medical records were provided by the prescriber to support this diagnosis. 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 plan is not required to cover Vraylar.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% ointment to treat polyosteoarthritis and fibromyalgia.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the requested documentation.Lidocaine 5% ointment is requested to treat polyosteoarthritis and fibromyalgia. However, there were no medical records submitted supporting your condition. The QIC is unable to determine if your condition is a medically-accepted indication to support the use of the requested drug.A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine 5% ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tacrolimus 1 milligram tablets.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the requested documentation.You requested Tacrolimus 1 milligram tablets. However, there were no medical records submitted supporting your condition. The QIC is unable to determine if your condition is a medically-accepted indication to support the use of the requested drug.A physician reviewed your appeal and determined that the plan is not required to cover Tacrolimus 1 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dronabinol 2.5 milligram capsule to treat moderate protein-calorie malnutrition and weight loss. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Vascepa 1 gram capsules prescribed for hyperlipidemia. The Part D plan denied the request for coverage because the drug was being prescribed for a non-medically accepted indication.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. During this review, we requested a statement and supporting medical records from the prescriber to clarify the provided diagnosis of hyperlipidemia and to address the plans coverage requirements for Vascepa. The prescriber did not respond to the request. The Medicare approved compendia do not contain any citations to support the use of the Vascepa for the treatment of hyperlipidemia. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the Vascepa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 10 milligram tablet prescribed for insomnia. The Part D plan denied your request for this High Risk medication based on answers given during the prior authorization process.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.. The documentation shows your doctor prescribed Zolpidem Tartrate to treat your insomnia. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. However, medical records were not received to 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. 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 Neupogen 300 microgram per 0.5 milliliter solution prefilled syringe prescribed for thrombocytopenia. 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.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.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 Neupogen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synthroid 150 microgram tablets prescribed for hypothyroidism. 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 requested additional information from your prescriber but did not receive a response. There is no supporting evidence that all the plans formulary, alternative drugs, have been tried.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 Synthroid.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% ointment 35.44 grams per 10 days. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.There was no diagnosis given at initial determination. At reconsideration the diagnosis of shingles pain was given. However, no medical records were submitted to support a diagnosis. Therefore, it cannot be determined if the requested drug was prescribed for a medically accepted indication supported by the Medicare approved compendia.A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine ointment. The prior authorization and quantity limit exception was not addressed because the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diphtheria, Tetanus, and Acellular Pertussis (TDAP) vaccine. 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 vaccine. We also asked for medical records and other documentation to show why you need this vaccine. We did not receive the documentation requested.The documentation shows you have a receipt for the TDAP vaccine and are requesting reimbursement. The TDAP vaccine is usually categorized as preventive and therefore not covered unless there is a specific covered diagnosis. In this case, no medical records were provided to support a specific covered diagnosis. We determined that the plan is not required to reimburse you for the TDAP vaccine. As such, payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Clotrimazole with Betamethasone Dipropionate 1%-0.05% cream, 540 grams per 90 days, prescribed for an unknown condition. The Part D plan denied the request because the amount prescribed exceeded the plans quantity limit of 135 grams per rolling 60-day period. 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.  The documentation does not include any medical records from the prescribing physician. During this review, a request was submitted to the prescriber to provide a diagnosis and supporting medical records and to address the need to exceed the amount of medication allowed by the plan. A reply from the prescriber was not received. Without a diagnosis it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested is not eligible for coverage under Medicare Part D. Additionally, since the drug is not eligible for coverage under Medicare Part D, the amount prescribed is no longer relevant to this review. A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 1.62% (2.5 gram) packet prescribed for hypogonadism. 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.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 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 Testosterone.