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

At issue is Auvi-Q 0.3 milligram/0.3 milliliter solution auto injector prescribed as directed for anaphylaxis prevention due to food allergy. The case was auto-forwarded by the plan.  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, specifically 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 Auvi-Q.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Quinine Sulfate 324 milligram capsules prescribed to take 1 capsule, by mouth, every day to treat alcoholic cirrhosis of the liver. 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 Quinine Sulfate 324 milligram capsules to treat alcoholic cirrhosis of the liver. 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 Quinine Sulfate 324 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ergocalciferol 1.25 milligram capsules prescribed for vitamin D deficiency. 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 Ergocalciferol because it is a prescription vitamin product. Drugs prescribed for prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations 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

The enrollee requested Prograf 1 milligram capsule prescribed daily to prevent rejection of kidney transplant. 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. We determined that the plan is not required to cover the Prograf. Medicare records indicate the enrollee received a kidney transplant on July 24, 2001, and the enrollee was eligible for Medicare Part A. Therefore, the transplant is considered a Medicare covered transplant and Prograf is eligible under Medicare Part B. Medicare rules state that a drug covered under Part B cannot be covered under Part D. 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: Favorable

At issue is Pantoprazole Sodium delayed release 40 milligram tablet prescribed for gastro-esophageal reflux disease. The Part D plan denied the request another similar drug was being given with no reason if the other drug would be discontinued.  We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted. This includes any information submitted at the reconsideration level. The documentation includes records the enrollee has a diagnosis of gastro-esophageal reflux disease. The physician indicates that upon the enrollees discharge from the last hospitalization, the second drug, Omeprazole, had been discontinued. The records include the hospital discharge summary that supports this. Medicare approved compendia support the use of the requested drug for the enrollees condition and the second drug in question, for the same condition, has been discontinued.  A physician reviewed your appeal and determined that the plan is required to cover Pantoprazole Sodium delayed release tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Invokana 300 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 not included on your plans formulary. 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 Pregabalin 75 milligram capsules prescribed as directed for bilateral sciatica and diabetic neuropathy. 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 received the documentation and included it in our review.Your medical records show your doctor prescribed Pregabalin to treat your bilateral sciatica and diabetic neuropathy. 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 your appeal and determined that the plan is not required to cover Pregabalin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Procrit 40000 unit/milliliter injection prescribed for unspecified anemia and iron deficiency. 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 requested additional documentation from the prescriber. Specifically, we requested a prescriber statement to support the enrollee met the plans prior authorization coverage criteria. We included the additional documentation in the review.The submitted documentation indicates the prescriber ordered Procrit for iron deficiency anemia, anemia due to gastrointestinal blood loss. The Medicare approved compendia do not support the use of the biologic at issue for the enrollees condition. As the biologic was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Butrans 20 microgram per hour transdermal patches prescribed for the treatment of chronic lower back pain. 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 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. Butrans is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale as to why all of the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. A physician reviewed the appeal and determined that the formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sirolimus 1 milligram tablet prescribed three tablets once daily for common variable immunodeficiency and Evans syndrome. 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 doctor prescribed Sirolimus to treat the enrollees common variable immunodeficiency and Evans syndrome. However, the Medicare approved compendia do not support the use of this drug for these conditions. A physician reviewed the appeal and determined that the plan is not required to cover Sirolimus.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tetracycline Hydrochloride 500 milligram capsules prescribed as directed for Helicobacter pylori intestinal infection. 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 Tetracycline Hydrochloride to treat your Helicobacter pylori intestinal infection. 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 Tetracycline Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 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. Eliquis is a brand drug on Tier 2 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 Ipratropium Bromide-Albuterol Sulfate 0.5/2.5 (3) milligrams/3 milliliter nebulizer solution prescribed for asthma. 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 drug at issue is for use in a nebulizer in the enrollees home. This is eligible for coverage under Part B. 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 Lidocaine 5% patch prescribed for neuropathic pain and pain in breast. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates the prescriber ordered Lidocaine 5% patch for neuropathic pain and pain in breast. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac sodium 1% Gel to treat chronic low 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 Diclofenac sodium1% Gel to treat your chronic low back pain. 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 Hyoscyamine 0.125 sublingual tablets prescribed for irritable bowel syndrome with constipation. 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 plan denied the request for coverage of the requested drug to treat the provided diagnosis because the plan cannot cover drugs classified as being part of the Food and Drug Administration Drug Efficacy Study Implementation program. These drugs are considered to be Less than Effective per Food and Drug Administration review.A physician reviewed your appeal and determined that the plan is not required to cover Hyoscyamine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vimpat 50 milligram tablets. The Part D plan denied the appeal request for a tiering exception.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.Vimpat is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Repatha SureClick 140 milligram per milliliter subcutaneous injection pen prescribed for the treatment of pure hypercholesterolemia. 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 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. Repatha SureClick is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the preferred formulary alternative included in the plan, Praluent, would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. A physician reviewed the appeal and determined that formulary exception criteria have not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cresemba 186 milligram capsules prescribed as directed for myelodysplastic syndrome, 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 information submitted at the reconsideration level. The documentation shows your doctor prescribed Cresemba to treat your myelodysplastic syndrome, unspecified. 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 Cresemba.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Savella 50 milligram tablet prescribed for fibromyalgia. 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 prescriber indicates they prescribed Savella to treat fibromyalgia. The medical record of July 6, 2021, supports a diagnosis of fibromyalgia and that the enrollee had tried and failed Lyrica (pregabilin). The documentation provided supports the plan's prior authorization requirements were met. A physician reviewed your appeal and determined that the plan is required to cover Savella.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mytesi 125 milligram DR tablets prescribed as directed for diarrhea in a patient receiving anti-retroviral therapy for an HIV infection. 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 medical records do not support why other drugs on the plans formulary, at the highest dosage, would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Mytesi.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium 3% gel prescribed for localized edema consistent with high-grade tendonosis and partial-thickness intrasubstance tearing. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates the prescriber ordered Diclofenac Sodium 3% gel for localized edema consistent with high-grade tendonosis and partial-thickness intrasubstance tearing. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humira CF 80 milligram/0.8 milliliter pen prescribed for pyoderma gangrenosum. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates the prescriber ordered Humira CF pen for pyoderma gangrenosum. The Medicare approved compendia do not support the use of the biologic at issue for the enrollees condition. As the biologic was not prescribed for a medically accepted indication, coverage cannot be allowed. This decision does not speak to the medical necessity of this drug for your condition. This decision speaks to whether your plan is required to provide coverage under Medicare rules.A physician reviewed the appeal and determined that the plan is not required to cover the requested biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ferosul 325 milligram(65  Fe) tablet prescribed for unknown diagnosis. 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 over-the-counter vitamins and minerals are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover the Ferosul. The plan indicates that supplemental benefits are not offered for this drug. 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: Favorable

At issue is Retacrit 10000 units/milliliter prescribed for anemia in chronic kidney disease. 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 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 requested additional information from the prescriber. The prescriber indicates they requested 40,000 units/milliliter. However, this review must be made on 10000 units/milliliter as first requested and is what the redetermination was reviewed for. The prescriber submitted recent laboratory studies that include a hemoglobin of 7.9 g/dl. The prescriber also confirms the enrollee is not on dialysis and the enrollee has no health problem or risk factor that may harm if taking the requested drug. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The prior authorization requirements have been met. A physician reviewed your appeal and determined that the plan is required to cover Retacrit 10000 units/milliliter.