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

At issue is a request for coverage of Xtampza ER 9 milligram capsule prescribed for chronic 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 records submitted at the reconsideration level. The documentation shows Xtampza ER was prescribed to treat chronic pain. Your plan has prior authorization requirements for this drug that must be met before they will cover Xtampza. 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 Xtampza. 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 request for coverage of Eliquis 5 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. Eliquis 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 a request for coverage of Ecocnazole Nitrate 1% cream. For initial determination and redetermination the diagnosis of hemorrhoids was given. 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. At reconsideration a diagnosis of skin breakdown in rectal area was given. However, the Medicare approved compendia do not support the use of Ecocnazole Nitrate for these conditions. A physician reviewed your appeal and determined that the plan is not required to cover Ecocnazole Nitrate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Sodium 3 percent gel prescribed as directed for strain of right knee and leg. 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 to treat your strain of right knee and leg. 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 3% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Lidocaine 5% patch for low back pain with sciatica. 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. The documentation shows Lidocaine 5% patch was prescribed to treat low back pain with sciatica. 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 Lidocaine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gentamycin Sulfate 40 milligram per milliliter in 0.9% Sodium Chloride solution prescribed to treat an enrollee with struvite, bladder stones, and urinary catheter obstruction. The Part D plan denied the appeal 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 Gentamycin Sulfate 40 milligram per milliliter in 0.9% Sodium Chloride solution to treat struvite, bladder stones, and urinary catheter obstruction. The prescriber also states that the enrollees urinary catheter requires frequent changing due to catheter obstruction and lack of efficacy of saline solution. 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 conditions.  Therefore, 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 Sulfate 40 milligram per milliliter in 0.9% Sodium Chloride solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Benztropine Mesylate 0.5 tablets prescribed for generalized anxiety 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 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 medical records indicate that Benztropine Mesylate is prescribed for generalized anxiety. 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 Benztropine Mesylate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Auryxia 210 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 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 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 Synthroid 112 microgram tablets. The Part D plan denied the appeal 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.Synthroid 112 microgram tablets 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 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 Nevanac 0.1% ophthalmic Solution one-drop in left eye twice daily to treat cystoid macular edema. 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. The Qualified Independent Contractor has made 2 or more attempts to request a case file or the returned case file request form indicating no coverage determination/no redetermination. We did not receive the requested information.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5 percent ointment prescribed as directed for pain in right 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 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 Lidocaine 5 percent ointment to treat your pain in right knee. 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 Lidocaine 5 percent ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Clinisol 15% Solution to treat unspecified protein-calorie malnutrition. 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.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Erythromycin 250-milligram Delayed Release 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 enrollee is requesting reimbursement for Erythromycin 250-milligram Delayed Release tablet given as self-administered while in the hospital. We researched Medicare resources and found that drug Erythromycin 250-milligram Delayed Release tablet is a repackaged drug with a National Drug Code that is not listed with the Food and Drug Administration. Therefore, we determined that the plan is not required to cover or provide reimbursement for the Erythromycin 250-milligram Delayed Release tablet. 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 Furosemide 60-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 enrollee is requesting reimbursement for Furosemide 60-milligram tablet given as self-administered while in the hospital. We researched Medicare resources and found that drug Furosemide 60-milligram tablet is a repackaged drug with a National Drug Code that is not listed with the Food and Drug Administration. Therefore, we determined that the plan is not required to cover or provide reimbursement for the Furosemide 60-milligram tablet. 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 Gemfibrozil 600 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 enrollee is requesting reimbursement for Gemfibrozil 600 milligram tablet given as self-administered while in the hospital. We researched Medicare resources and found that drug Gemfibrozil 600 milligram tablet is a repackaged drug with a National Drug Code that is not listed with the Food and Drug Administration. Therefore, we determined that the plan is not required to cover or provide reimbursement for the Gemfibrozil 600 milligram tablet. 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 Isosorbide Mononitrate 30-milligram Extended Release 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 enrollee is requesting reimbursement for Isosorbide Mononitrate given as self-administered while in the hospital. We researched Medicare resources and found that drug Isosorbide Mononitrate 30-milligram Extended Release tablet is a repackaged drug with a National Drug Code that is not listed with the Food and Drug Administration. Therefore, we determined that the plan is not required to cover or provide reimbursement for the Isosorbide Mononitrate tablet. 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 Klor-Con 20-milli-equivalents 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 enrollee is requesting reimbursement for Klor-Con 20-milli-equivalents tablet given as self-administered while in the hospital. We researched Medicare resources and found that drug Klor-Con 20-milli-equivalents tablet is a repackaged drug with a National Drug Code that is not listed with the Food and Drug Administration. Therefore, we determined that the plan is not required to cover or provide reimbursement for the Klor-Con 20-milli-equivalents tablet. 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 Montelukast 10-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 enrollee is requesting reimbursement for Montelukast 10-milligram tablet given as self-administered while in the hospital. We researched Medicare resources and found that drug Montelukast 10-milligram tablet is a repackaged drug with a National Drug Code that is not listed with the Food and Drug Administration. Therefore, we determined that the plan is not required to cover or provide reimbursement for the Montelukast 10-milligram tablet. 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 Sucralfate 1-Gram 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 enrollee is requesting reimbursement for Sucralfate 1-Gram tablet given as self-administered while in the hospital. We researched Medicare resources and found that drug Sucralfate 1-Gram tablet is a repackaged drug with a National Drug Code that is not listed with the Food and Drug Administration. Therefore, we determined that the plan is not required to cover or provide reimbursement for the Sucralfate 1-Gram tablet. 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

At issue is Julica 50/25 milligram tablet. 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 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 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 Pradaxa 150 milligram capsules prescribed to treat an enrollee with transverse sinus thrombosis in the setting of a traumatic brain injury. 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 doctor prescribed Pradaxa 150 milligram capsules to treat transverse sinus thrombosis in the setting of a traumatic brain injury.  However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. In addition, although new or revised documentation has been submitted for review, this does not changed the QICs initial decision.A physician reviewed the appeal and determined that the plan is not required to cover Pradaxa 150 milligram capsules.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Osphena 60 milligram tablet prescribed for post-menopausal atrophic vaginitis..   The Part D plan denied the request.  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.  We also asked for and received additional medical records and a prescriber statement and included it in our reveiw.    The documentation satisfies the plans coverage criteria.  A physician reviewed your appeal and determined that the plan is not required to cover Osphena.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zetia 10 milligram tablets prescribed to treat an enrollee with unspecified hyperlipidemia. The Part D plan denied the appeal 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 your condition. We also asked for medical records or other documentation (clarification of diagnosis and a prescribers statement) to show why the enrollee needs this medication. We did not receive a prescribers statement or supporting medical records.The documentation shows the doctor prescribed Zetia 10 milligram tablets to treat unspecified hyperlipidemia. The use of the requested drug to treat the provided diagnosis is an off-label use. The Part D plan denied the request stating the formulary exception criteria was not satisfied. However, 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 (unspecified hyperlipidemia). 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 Zetia 10 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methocarbamol 750 milligram tablets prescribed as directed for 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. 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 the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. . We received the documentation and included it in our review.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 Methocarbamol.