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

The enrollee requested compounded drug SPG Suppository base pellet/Diazepam powder/Silica gel prescribed for pelvic pain. The plan denied the enrollees request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.We determined that the plan is not required to cover or provide reimbursement for the compounded drug SPG Suppository base pellet/Diazepam powder/Silica gel. According to Medicare rules, drugs that fall into the category of bulk powders are excluded from coverage under Part D. The Diazepam powder, does not meet the definition of a Part D drug because it is considered a bulk powder. We reviewed Food and Drug Administration (FDA)-approved sources for the drugs classification or determined from other available resources that the SPG Suppository base and Silica gel are non-prescription or over-the-counter drugs. Therefore, the ingredients SPG suppository base and Silica gel are not eligible for Part D coverage. 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 Lantus Solostar 100-units/milliliter to treat an unknown diagnosis. The Part D plan denied the request. The case was auto-forwarded by the plan.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.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 (diagnosis). Additionally, 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 physician did not submit medical records supporting why other drugs on the plans formulary would not work for you. Talk with your physician to determine what drugs on your formulary are available for you to try to treat your condition. As such, the requested drug is not eligible for coverage under Medicare Part D. Your plan is not required to reimburse you for the cost of the drug at this time.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 Xeljanz 5 milligram tablets prescribed to treat an enrollee with severe calcinosis cutis associated with systemic sclerosis. 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 Xeljanz 5 milligram tablets to treat severe calcinosis cutis associated with systemic sclerosis. 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 Xeljanz 5 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Sivextro 200 milligram tablet prescribed for mycobacterium avium complex infection and pulmonary mycobacterial infection. 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 Sivextro was prescribed to treat mycobacterium avium complex infection and pulmonary mycobacterial 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 Sivextro.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prolia 60-milligrams/milliliter/syringe Subcutaneous two-syringes/180-days to treat 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.The plan limits the amount of Prolia to 60-milligrams/milliliter/syringe, one-syringe/180-days. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the condition or would be likely to cause harm. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that quantity limit criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Xospata 50 milligram tablet prescribed for T-cell precursor acute lymphoblastic leukemia. 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 Xospata was prescribed to treat T-cell precursor acute lymphoblastic leukemia. 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 Xospata.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tremfya 100 milligram/milliliter injection prescribed as directed for plaque psoriasis. 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 Tremfya.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Nuedexta 20-10 milligram capsules prescribed for pseudobulbar affect. The Part D plan denied coverage.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 records submitted at the reconsideration level. We requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the enrollee met the plans prior authorization coverage criteria. We received the information and included it in the review.The documentation on hand includes a physician supporting statement. The supporting statement does not indicate that the enrollee satisfies the plan's prior authorization 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 a request for coverage of Mektovi 15 milligram tablet prescribed to treat non-small cell lung cancer. 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 Mektovi was prescribed to treat non-small cell lung cancer. 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 Mektovi.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Adacel Dtap vaccine prescribed for vaccination. The Part D plan denied the reimbursement 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 plan submitted documentation that shows the enrollee was still in the deductible stage of the Part D benefit when the Adacel Dtap was purchased. The plans Evidence of Coverage states that the enrollee is responsible for the full cost of covered drugs until the deductible amount is satisfied. In this case, the amount the enrollee paid for the Adacel Dtap vaccine was $100. The plan approved the drug for an amount of $95. This amount was applied to the enrollees deductible correctly. We determined that no additional reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lovaza 1 gram capsules prescribed for dyslipidemia. 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 requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support the plans formulary alternatives were tried and failed or were contraindicated. However, 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 the enrollee. A physician reviewed the appeal and determined that the plan is not required to cover Lovaza.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Praluent 150 milligram/milliliter injection solution. 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 requested additional documentation from the prescriber. Specifically, we requested medical records to support a covered diagnosis and a prescriber statement to support the enrollee met the plans prior authorization coverage criteria. However, we did not receive the requested information.The documentation does not contain clinical information to support a prescribed diagnosis. As it cannot be determined the biologic at issue was 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 Praluent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Emgality 120 milligram/milliliter solution auto-inject prescribed for migraine without status migrainosus, not intractable. 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. The documentation shows Emgality was prescribed to treat migraine without status migrainosus, not intractable. 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 Emgality. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliquis 5-milligram tablet to treat multiple deep vein thromboses. 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.This drug is being 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.Our physician reviewer's opinion is that non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Memantine HCL ER 28 milligram capsule.  At initial determination and redetermination the diagnosis of frontotemporal dementia 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.We asked the 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 the enrollee. We received the documentation and included it in our review. At reconsideration a diagnosis of Alzheimers disease was given. We did not receive medical records to support this diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. As such, Memantine HCL does not satisfy the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D. Since the Memantine HCL is not eligible for coverage under Part D, the plans formulary exception requirements are not applicable to this review. A physician reviewed your appeal and determined that the plan is not required to Memantine HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Budesonide 0.5 milligram/2 milliliter suspension prescribed for the treatment of chronic obstructive pulmonary disease with acute exacerbation. The Part D plan denied the enrollees request.We received the 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. The record shows the Budesonide is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover the Budesonide. Please consider submitting this request to Medicare Part B. 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 a request for coverage of Renacidin irrigation solution prescribed for calculus in 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. 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 the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Renacidin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Procrit 20000 unit intramuscular injection prescribed for anemia in chronic kidney disease. 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.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 the enrollee. A physician reviewed the appeal and determined that the plan is not required to cover Procrit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for Lidocaine 5% patch for lumbar spinal stenosis, lumbar spondylosis and cervical spondylosis. 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 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.The documentation shows Lidocaine 5% patch was prescribed to treat lumbar spinal stenosis, lumbar spondylosis and cervical spondylosis. 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 Rezurock 200 milligram tablet prescribed for graft versus host disease in an enrollee with acute myeloid leukemia who underwent a stem cell transplant in 2018. 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. Medicare records show the enrollee had a stem cell transplant while covered under Medicare Part A. Immunosuppressant drugs prescribed for enrollees who receive a transplant from a Medicare-approved facility and were entitled to Medicare Part A at the time of the transplant, are covered under Part B. This drug is not eligible for coverage under Part D drug benefits but may be covered under Medicare Part B benefits. We determined that the plan is not required to cover Rezurock.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Benztropine Mesylate 2 milligram tablets prescribed for extrapyramidal symptoms. The Part D plan denied coverage.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 records submitted at the reconsideration level. The documentation on hand includes a physician supporting statement. The supporting statement does not indicate that the enrollee satisfies the plan's prior authorization 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 Aplenzin 174-millgram Extended Release tablet to treat depression. 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

At issue is a request for coverage of Xeljanx 5 milligram tablet prescribed for refractory dermatomyositis. 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 Xeljanx was prescribed to treat refractory dermatomyositis. 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 Xeljanx.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate Mofetil 500 milligram tablets prescribed for dermatopolymyositis. The Part D plan denied the request.  We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows the prescriber ordered Mycophenolate Mofetil for dermatopolymyositis. 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 Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Opsumit 10 milligram tablet prescribed as directed for severe pulmonary hypertension. 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 Opsumit.