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

You requested Otezla 10-20-30 milligram tablet dose pack prescribed as directed for lichen planus. 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 Otezla to treat your lichen planus. 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 Otezla.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Epolamine 1.3 percent topical patch 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aduhelm 300 milligram/3 milliliter solution prescribed for Alzheimers. The Part D plan denied the request. We performed 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 biologic at issue is given via infusion. This is eligible for coverage under Part B. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. 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

You requested Diclofenac Sodium 1 percent gel prescribed as directed for other intervertebral disc displacement, lumbar region, post laminectomy syndrome, not elsewhere classified, and fusion of spine, cervical region. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows your doctor prescribed Diclofenac Sodium to treat your other intervertebral disc displacement, lumbar region, post laminectomy syndrome, not elsewhere classified, and fusion of spine, cervical region. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Praluent 75 milligram/milliliter subcutaneous auto-injector pen prescribed for 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 records 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 Enrollee needs this medication. We did not receive the documentation requested.The medical records show the doctor prescribed Praluent to treat the Enrollees hyperlipidemia. 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 the appeal and determined that the plan is not required to cover Praluent. 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 Promacta 75 milligram tablet prescribed for aplastic anemia. 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 medical records support the doctor prescribed Promacta to treat the Enrollees aplastic anemia. 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 the appeal and determined that the plan is not required to cover Promacta. The physician has not documented the Enrollee will also be taking antithymocyte globulin and cyclosporine. 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 Lidocaine 5 percent ointment prescribed as directed for severe chronic back pain and degenerative 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 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 severe chronic back pain and degenerative disease. 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. Prior authorization requirements were not met therefore quantity limits were not considered.A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine 5 percent ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Lidocaine 5% patches prescribed for sciatica. The Part D plan denied the request. We performed 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 submitted documentation does not include medical records or a supporting statement. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Morphine Sulfate 30 milligram Extended Release tablet prescribed for chronic pain syndrome. 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. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. Your prescriber submitted documentation of the nature and intensity of pain, past and current treatments, and the Enrollees history. There is an agreement signed by the Enrollee and the state controlled substance database was checked. A treatment plan is in place and a risk assessment had been completed. However, the documentation provided does not support concurrent use of Medicated Assisted Treatment or an attestation from the provider that the Enrollee experienced previous treatment with short-acting opioids at the lowest dose possible as calculated using morphine milligram equivalent. The records do not support the plan's prior authorization requirements have been satisfied. A physician reviewed your appeal and determined that the plan is not required to cover Morphine Sulfate Extended Release tablets. 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 Kynmobi 10 milligram film prescribed as directed for Parkinson's 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 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 Kynmobi to treat your Parkinson's disease. 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 Kynmobi.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollee requested compounded drug Estradiol 0.015% vaginal cream prescribed for unknown diagnosis. 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.According to Medicare rules, drugs that fall into the category of bulk powders are excluded from coverage under Part D. The Estradiol micronized powder does not meet the definition of a Part D drug. In addition, Medicare Part D does not cover non-prescription drugs. We reviewed Food and Drug Administration (FDA)-approved sources for the drugs classification or determined from other available resources that the drugs are non-prescription or over-the-counter (OTC) drugs. Therefore, the ingredient Versabase cream is not eligible for Part D coverage. Therefore, we determined that the plan is not required to cover the Estradiol 0.015% vaginal cream compound. 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 Tecfidera Starter Pack 120 and 240 milligram prescribed twice daily for relapsing multiple sclerosis. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. We asked the prescriber to send us information regarding your 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. Additionally, we requested a list of formulary drugs/formulary for this 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 Tecfidera.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium 3% gel prescribed every twice daily for pain in right wrist and shoulder. 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 doctor prescribed Diclofenac Sodium 3% gel to treat the enrollees right wrist and shoulder pain. At reconsideration a diagnosis of osteoarthritis was given. However, no medical records were provided, by the prescriber, to support a medically accepted indication. The diagnoses provided are not medically accepted indications. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the plan is not required to cover Diclofenac Sodium 3% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram tablet. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Eliquis is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Budesonide 0.5 milligram per 2 milliliter nebulizer ampules. The Part D plan denied the request for coverage stating that the drug would not be covered under Medicare Part D, as the drug was being used with a nebulizer. 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 the Budesonide nebulizer ampules are not being used with a nebulizer. The drug is being used as part of a nasal irrigation solution to treat chronic sinusitis. However, the Medicare approved compendia do not contain any citations to support the use of Budesonide nebulizer ampules, as prescribed, for the treatment of the noted conditions. 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 Nucynta 50 milligram tablet prescribed twice daily for chronic 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 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 Nucynta to treat the Enrollees chronic back pain. 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 Nucynta. The request for a formulary exception was not reviewed. We cannot consider a formulary exception for a drug for which the Medicare Part D plan is unable to provide coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tecfidera DR 240 milligram capsule 180 tablets prescribed twice daily for multiple sclerosis. 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 indicates the doctor prescribed Tecfidera DR to treat the Enrollees multiple sclerosis. The drug at issue was approved as a specialty drug, which is only approved for a 30 day supply. An exception to the quantity limit criteria was not met.Therefore, the plan is not required to cover Tecfidera DR for a quantity limit exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mercaptopurine 50 milligram tablets prescribed as directed. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. This drug is included on Tier 1 of the plans formulary. There are no cost-sharing tiers lower than Tier 1; therefore, a tier exception cannot be considered.  A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Diclofenac Sodium 3% gel. 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 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 Diclofenac Sodium gel has been prescribed for the treatment of lumbar pain and radiculopathy secondary to lumbar disc degeneration, compression of lumbar vertebrae, lumbar stenosis, and lumbar facet hypertrophy. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted conditions. Therefore, the drug is being prescribed for non-medically accepted indications 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

You requested Freestyle Libre sensor prescribed as directed for the enrollees condition. 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 record shows Freestyle Libre sensor is not directly related to the delivery of insulin to the body. However, this drug may be eligible for coverage under Medicare Part B. Medicare Part B covers medical supplies that are not directly related to the delivery of insulin to the body. Test strips, lancets, and needle disposal systems are included in this category. They are covered by Medicare Part B. We cannot pay for drugs under Medicare Part D if they are covered under Medicare Part A or B.We determined that the plan is not required to cover Freestyle Libre sensor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Brinzolamide 1% ophthalmic suspension prescribed for bilateral ocular hypertension. 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. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The plan has a step therapy requirement for Brinzolamide 1% ophthalmic suspension. Before this drug is covered, the enrollee must have tried and failed or have a contraindication to both Dorzolamide and Brimonidine. The submitted documentation does not support that the plans prior step therapy requirements have not been satisfied. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methadone Hydrochloride 5 milligram oral tablet prescribed daily for restless leg syndrome. 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 Methadone Hydrochloride to treat restless leg syndrome, severe with signs of augmentation. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Methadone Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ajovy solution auto-inject 225 milligram/1.5 milliliter prescribed for chronic intractable migraine without aura. 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 and prescribers statement 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 Ajovy.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Proair HFA Aerosol Solution 108 (90 Base) microgram/actuation 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 provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.A physician reviewed 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 Calcitriol 0.5 microgram capsules prescribed daily for hypocalcemia secondary to dialysis and 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. According to Medicare rules, the requested drug is eligible for coverage under the Part B end stage renal disease payment bundle. Drugs which are eligible for Part B coverage are excluded from Part D coverage. We determined that the plan is not required to cover the Calcitriol. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.