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

At issue is a request for coverage of Methotrexate 25 milligram per milliliter vial prescribed for psoriatic arthritis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The Food and Drug Administration is unable to provide regulatory status determinations through their regular processes if a drug product is not properly listed. Therefore, Part D sponsors should confirm that a prescription drug product National Drug Code (NDC) is properly listed with the Food and Drug Administration. The National Drug Code submitted for this drug indicates it is not an FDA-approved drug. Please ask your pharmacy to resubmit the request with a registered National Drug Code. We have determined that the Medicare Part D plan is not required to cover the requested drug. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fasenra 30 milligrams per milliliter auto-injector pen prescribed to treat asthma caused by eosinophils. 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.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 Fasenra 30 milligrams per milliliter auto-injector
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Premarin 0.3 milligram tablet prescribed for hot flashes. 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. 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. Although the prescriber indicates Estradiol weekly patches 0.025 milligram had been tried and failed, there was not a second formulary alternative tried and failed which is required by the plan. In this case, the medical records do not support why all the 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 Premarin tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Januvia 100 milligram tablets prescribed for the treatment of type 2 diabetes mellitus. 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. Januvia is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil Citrate 50 milligram tablet prescribed for male erectile dysfunction. 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. The documentation indicates Sildenafil Citrate 50 milligram tablet is prescribed for male erectile dysfunction. Drugs used to treat sexual or erectile dysfunction are excluded from Medicare Part D drug benefits. A physician reviewed your appeal and determined that the plan is not required to cover Sildenafil Citrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Cresemba. 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 indicates that Cresemba has been prescribed for the treatment of coccidioidomycosis meningitis. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Pregabalin 50 milligram capsules prescribed for diabetic peripheral neuropathy. 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. The plan has prior authorization requirements that must be met before coverage of this medication will be approved. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. 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 Pregabalin 50 milligram capsules prescribed to treat trigeminal neuralgia. 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 Pregabalin 50 milligram capsules to treat trigeminal neuralgia. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed the appeal and determined that the plan is not required to cover Pregabalin 50 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Livalo 2 milligram tablets prescribed for mixed hyperlipidemia. 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 supporting statement to support all formulary alternatives were tried and failed. However, we did not receive the requested 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 your appeal and determined that the plan is not required to cover Livalo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dextroamphetamine/Amphetamine Extended Release 10 milligram capsule prescribed for attention deficit hyperactivity 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 support the prescriber requests Dextroamphetamine/Amphetamine Extended Release 10 milligram capsules to treat attention deficit hyperactivity disorder. Medicare approved compendia support the use of this drug for this condition. However, the extended release version of this drug, Dextroamphetamine/Amphetamine, is not on the plans formulary. 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 all the other drugs on the plans formulary would not work.A physician reviewed your appeal and determined that the plan is not required to cover Dextroamphetamine/Amphetamine Extended Release capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrocort-Pramoxine cream 1% prescribed twice daily for unspecified hemorrhoids. 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 medication was needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. However, we did not receive the documentation.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work. A physician reviewed the appeal and determined that the plan is not required to cover Hydrocort-Pramoxine cream 1%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Euflexxa Solution Prefilled syringe 20 milligram/ 2 milliliter to treat osteoarthritis of the knee. 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 records indicate the drug is requested by the prescriber for pain due to osteoarthritis. The office visit note indicates the prescriber will notify the enrollee when the medication has been received. A drug provided and administered by the prescriber is subject to Part B coverage and is not eligible under Part D drug benefits.  We determined that the plan is not required to cover Euflexxa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue a request for coverage of Pentamidine Isethionate 300 milligram solution for reconstitution prescribed for infection prophylaxis in an immunocompromised enrollee with multiple myeloma and history of stem cell transplant. 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 indicates that the Pentamidine Isethionate is going to be administered via nebulizer. Medicare rules state that Medicare Part B pays for the rental and purchase of durable medical equipment, such as a nebulizers. Payment will also be made under Medicare Part B for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals, which must be put directly into the equipment to achieve the therapeutic benefit of the durable medical equipment. Coverage under Part D is excluded for any drug for which payment would be available under Part B. We have determined that the Medicare Part D plan is not required to cover the requested drug. 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 Lyrica 50 milligram capsule prescribed for chronic low back pain. 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 show Lyrica 50 was prescribed for chronic low back pain. 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 Lyrica.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Ztlido 1.8% patch prescribed for intervertebral disc disorder with radiculopathy, lumbar region. 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 medical records and a supporting statement. However, we did not receive additional information.The submitted documentation indicates the prescriber ordered Ztlido for intervertebral disc disorder with radiculopathy, lumbar region. 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 a prior authorization request for Temazepam 30 milligram capsules prescribed for insomnia. 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 documentation from the prescriber. Specifically, we requested medical records and a supporting statement. However, we did not receive additional information.The documentation on hand 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 quantity limit exception for Atorvastatin Calcium 10 milligram tablets prescribed for mixed hyperlipidemia. 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 medical records and a supporting statement. However, we did not receive additional information.The documentation indicates the prescriber ordered Atorvastatin Calcium for mixed hyperlipidemia. The prescriber requested 60 tablets for a 30-day supply. The plan allows 30 tablets for a 30-day supply. The documentation on hand does not support the medical necessity for a supply greater than the plans allowance, nor does the documentation support why the enrollee cannot take a higher dose of the same medication. Therefore, a quantity limit exception cannot be granted and the amount approved by the plan is upheld.Therefore, the plan is not required to cover Atorvastatin Calcium for a quantity limit exception.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Lidocaine 5 percent ointment prescribed for unspecified multiple injuries, initial encounter. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Lidocaine 5 percent ointment to treat your open sores related to bilateral edema of legs for 30 days. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. A physician reviewed your appeal and determined that the plan is required to cover Lidocaine 5 percent ointment. The medical records indicate that Lidocaine 5 percent ointment was prescribed for 30 days to the bilateral legs. The records further indicate the enrollee has open sores related to the edema. The documentation provided does show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to grant your request for prior authorization.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Calcipotriene 0.005% ointment prescribed to treat plaque psoriasis.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.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 Calcipotriene 0.005% ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Emsam 6 milligrams per 24 hour patch. 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.Emsam 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 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 Alprazolam ER 0.05 milligram extended release tablets prescribed for paresthesia of the skin. The Part D plan approved coverage for the drug. However, the plan denied the request for more than a recurring 30-day supply.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. Alprazolam ER is a benzodiazepine. Drugs, such as benzodiazepines, are limited to a recurring 30-day supply by the plan. An exception to the quantity limit criteria has not been met. A physician reviewed the appeal and determined that the plan is not required to cover more than a recurring 30-day supply of the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Adderall 20 milligram tablets prescribed for narcolepsy. 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. Adderall 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 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 Phytonadione 5 milligram tablet prescribed for vitamin deficiency. 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 drug requested is a prescription vitamin. Vitamins and minerals are excluded from coverage under Medicare Part D drug benefits.A physician reviewed your appeal and determined that the plan is not required to cover Phytonadione.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Hydroxyzine Hydrochloride 50 milligram tablets prescribed for pruritis. 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 documentation from the prescriber. Specifically, we requested medical records and a supporting statement. However, we did not receive additional information.The documentation on hand 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 Lidocaine 5% patch. 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 medical records and a supporting statement. However, we did not receive additional information.The submitted documentation does not contain evidence of a prescribed diagnosis. As it cannot be determined that the drug 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 the requested drug.