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

You requested Baclofen 5 milligram tablet prescribed for ankylosing spondylitis and lumbar radiculopathy. 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 Baclofen to treat your ankylosing spondylitis and lumbar radiculopathy. 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 Baclofen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrocodone Acetaminophen 5-325 milligram tablet prescribed four times daily for chronic low back pain due to lumbar disc degeneration, discitis, and osteomyelitis. 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.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 received the documentation and included it in our review.The medical records show the doctor prescribed Hydrocodone Acetaminophen 5-325 milligram tablet to treat the enrollees chronic low back pain. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed the appeal and determined that the plan is not required to cover Hydrocodone Acetaminophen 5-325 milligram tablet. 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: Favorable

At issue is Engerix-B prescribed day one, day 30, and day 180 for hepatitis B prophylaxis. 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 determined that the drug is not eligible for Part B coverage. The enrollee is not at intermediate or high risk of contracting hepatitis B. Therefore, the drug can be considered for payment under the Part D benefit. The doctor prescribed Engerix-B for the enrollees hepatitis B prophylaxis. The following citation was referenced in DrugDex, a Medicare approved compendia, and supports the use of this drug for the enrollees condition: Recombinant hepatitis B vaccine is recommended in patients receiving care in facilities in which high proportions of adults are at risk of hepatitis B infection (drug abuse treatment and prevention services). The following citation was referenced in the American Hospital Formulary Service Drug Information, a Medicare approved compendia, and supports the use of this drug for the enrollees condition: Individuals with chronic hepatitis C virus (HCV) infection may be at increased risk for hepatitis B virus exposure and should receive hepatitis B vaccine. The prescriber states the enrollee is engaged in substance use disorder treatment at their office and has chronic hepatitis C.A physician reviewed this appeal and determined that the plan is required to cover Engerix-B.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollee requested Albuterol Sulfate HFA 90 microgram prescribed for an unknown diagnosis. 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 record shows the plan reprocessed a claim for the Albuterol Sulfate HFA and adjusted the amount owed due to the Enrollees true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the Enrollees deductible had not been met at the time of purchase. Therefore, the plan recalculated and the Enrollee's share of the cost was applied to the Enrollee's deductible. We have determined that the plan is correct in its calculation of the owed amount towards the Enrollee's deductible.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 24-26 milligram tablet prescribed twice daily for chronic heart failure. The Part D plan denied the 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. A request for reimbursement was received. If the enrollee pays the full cost of a prescription, then they may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that the enrollee paid for the drug was not provided. Therefore, we determined that the plan is not required to reimburse the enrollee without the required documentation.Entresto 24-26 milligram tablet 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

You requested Nystatin external cream 100,000 unit/gram ointment prescribed 60 grams for 8 days to treat dermatitis. 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 the Enrollee's condition. We also asked for medical records or other documentation to show why this amount of the medication is needed. We did not receive the documentation requested. The documentation shows Nystatin was prescribed to treat dermatitis. However, medical records were not received to support why an exception to the plans quantity limit is medically necessary. A physician reviewed your appeal and determined that the plan is not required to cover the Nystatin, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azathioprine 50 milligram tablet prescribed for chronic inflammatory demyelinating polyneuropathy. 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 Azathioprine was prescribed to treat the Enrollees chronic inflammatory demyelinating polyneuropathy. 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 Azathioprine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a direct member reimbursement for the non-formulary drug Febuxostat 40 milligram tablets. 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 does not contain medical records to support the prescribed diagnosis for Febuxostat. A request for documentation was sent to the prescriber; however, no further information was received. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Benzonatate 100 milligram capsule prescribed for cough. The Part D plan denied the request. We performed and 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 Benzonatate because it was for the symptomatic relief of coughs and colds. Drugs prescribed for symptomatic relief of cough and colds 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

At issue is Qsymia 11.25 milligram/69 milligram capsule prescribed for obesity. The Part D plan denied the request. We performed and 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 Qsymia because it was used to treat obesity. Drugs prescribed to treat weight gain (promote weight loss) 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

At issue is Cosentyx 150 milligram/milliliter pen injector 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.Cosentyx is a brand drug on Tier 5 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 Fetzima ER 40 milligram capsule 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. Fetzima ER is a brand drug on Tier 4 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 Myrbetriq ER 50 milligram tablet prescribed daily. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. We reviewed all documentation submitted. Myrbetriq ER 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

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 Cresemba at issue was prescribed for coccidiodomycosis meningitis. 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 your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Brilinta 90 milligram oral tablet prescribed daily. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Brilinta is a brand drug on Tier 4 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 Welchol 625 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 Accu-Check test strips. 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 item at issue is not directly related to the delivery of insulin. 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: Favorable

At issue is Xtandi 40 milligram capsule prescribed four per day for metastatic castrate resistant prostate 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 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 medical records show the doctor prescribed Xtandi to treat the enrollees metastatic castrate resistant prostate cancer. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. Per prior authorization requirements, all medically accepted indications are accepted. Per the Food and Drug Administration, the indications state that Xtandi is indicated for castrate resistant prostate cancer but doesnt specifically say if it should be metastatic. The compendia support the use of Xtandi in metastatic castrate resistant prostate cancer. DrugDex states that it is a Class 2a recommendation that Xtandi be used in metastatic castrate resistant prostate cancer. In addition, the National Comprehensive Cancer Network states that Xtandi can be used as secondary hormone therapy for castrate resistant prostate cancer, metastatic, if no prior Docetaxel and no prior novel hormone therapy. This is a category 1 recommendation by the National Comprehensive Cancer Network. The prescriber notes that Xtandi will be used with Lupron, which is indicated by the National Comprehensive Cancer Network. The documentation provided shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Xtandi.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Spravato 84 milligram spray prescribed 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.The record shows Spravato is being prescribed to the Enrollee for treatment of depression. Medicare law specifically excludes coverage for any drug for which payment would be available under Medicare Parts A or B for that individual. Medicare Part B pays for services and supplies incident to the service of a physician (or other practitioner). Spravato is a type of drug that must be administered under direct observation of a health care provider and monitored for at least two hours after administration. The Food and Drug Administration has mandated a Risk Evaluation and Mitigation Strategy for Spravato. This strategy requires that Spravato be only dispensed and administered to patients in a medically supervised healthcare setting that monitors the enrollee. We determined that the drug is eligible under Medicare Part B. Therefore, the Part D plan is not required to cover Spravato. 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 Mekinist 2 milligram tablet prescribed for neurofibromin 1 (NF1) mutated squamous cell carcinoma of the lung. 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 records submitted at the reconsideration level.The documentation shows the doctor prescribed Mekinist to treat the enrollees neurofibromin 1 (NF1) mutated squamous cell carcinoma of the lung. However, the Medicare approved compendia do not support the use of this drug for this condition. There was no peer-reviewed, clinically relevant, medical literature from an approved journal submitted to support this appeal.A physician reviewed the appeal and determined that the plan is not required to cover Mekinist.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trospium Chloride 20 milligram tablet prescribed twice daily for overactive bladder. 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 the Enrollee needs the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the Enrollee. 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 the Enrollee. A physician reviewed the appeal and determined that the plan is not required to cover Trospium Chloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azelastine 0.15% nasal spray prescribed for allergic rhinitis. 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 and other documentation to show why the medication is needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the enrollee. 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, no medical records were provided to 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 Azelastine 0.15% nasal spray.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a direct member reimbursement request for Acyclovir 400 milligram tablets. 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 does not include medical records to support a covered diagnosis. A request for information was sent to the prescriber; however, no further documentation was received. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.