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

At issue is reimbursement for Shingrix vial kit  prescribed for shingles vaccination. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 plans Evidence of Coverage states, reimbursement for drugs administered to an enrollee for an out of network provider, or prescribers office, are based on the amount paid for the drug, less any deductible, copayment or coinsurance, less the amount the physician charges, and the plans approved amount. The plan submitted documentation showing the enrollee was reimbursed for the plans share of the cost for the requested drug and administration fee. Therefore, we determined that the plan is not required to provide further reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pimecrolimus 1 percent cream prescribed as directed for intertrigo. 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 Pimecrolimus to treat your intertrigo. 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 intertrigo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate Mofetil 500-milligrams prescribed for sarcoidosis, unspecified. 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 submitted shows the prescriber ordered Mycophenolate Mofetil to treat the enrollees condition of sarcoidosis, unspecified. 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 Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trimo-San 0.025-0.01 jelly prescribed for unknown diagnosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 requested drug has not been approved by the Food and Drug Administration to be safe and effective. Therefore, we determined that the plan is not required to cover the Trimo-San jelly.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5 percent ointment prescribed as directed for other specified disorders of bone density and structure, neuropathy related to osteopenia. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.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.  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 Zarxio 480-microgram/0.8-milliliter solution prescribed for neutropenia secondary to immunosuppressive therapy status post cardiac transplant. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates the prescriber ordered the biologic at issue for the enrollees noted condition. The Medicare approved compendia do not support the use of the biologic at issue for the enrollees condition. As the biologic was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested biologic.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gleostine 100 milligram capsules prescribed to treat the diagnosis of glioblastoma. 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.According to Medicare rules, Part D drug plans do not cover drugs produced by a manufacturer who does not participate in the Medicare Part D program. The Center for Medicare and Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. According to this list, the manufacturer, Nextsource Biotechnology, LLC, has not sign the agreement and does not participate in the Medicare Gap Discount Program. Therefore, we determined that the plan is not required to cover Gleostine. 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

You requested Zortress 0.5-milligram tablets  prescribed as directed for status post heart/liver transplant. 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 Zortress to treat your status post heart/liver transplant. 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 Zortress.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Reclast 5 milligram/100-milliliter injection prescribed as directed for age related osteoporosis. 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 Reclast.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Droxidopa 200 mg capsules prescribed as directed for neurogenic orthostatic hypotension. 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 Droxidopa to treat your neurogenic orthostatic hypotension. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. 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 cover Droxidopa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Sildenafil Citrate 20-milligram tablets. 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. The available documentation does not include the enrollees diagnosis to determine if the drug is being prescribed for a medically accepted indication. During this review, several attempts were made to contact the prescriber to provide the enrollees diagnosis and to address the plans prior authorization requirements for coverage of this this drug. However, the prescriber was unable to be reached by fax or phone. Therefore, it cannot be determined if the requested drug is being prescribed for a medically accepted indication. As such, the 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 the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Fosfomycin Tromethamine 3-gram packet to treat urinary tract infection, site not specified. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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.A physician reviewed the request and determined that the requested drug is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vraylar 1.5 milligram capsules prescribed as directed for schizoaffective disorder, bipolar. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. Your medical records show your doctor prescribed Vraylar to treat your schizoaffective disorder, bipolar. 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 Vraylar.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Imbruvica 140 milligram capsule, 90 capsules per 30 days, prescribed for monoclonal gammopathy. 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 prescriber clarified the diagnosis in the request for reconsideration.  Medical records from date of service 9/2/2021 were submitted which document that the requested drug is being used for the treatment of Waldenstrom macroglobulinemia. Medicare approved compendia support the use of this drug for the enrollee's condition. Therefore, it is considered a medically accepted indication.  The documentation satisfies the plans coverage criteria.  A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine 5 milligram tablets prescribed as directed for chronic muscle spasms. 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 Cyclobenzaprine to treat your chronic muscle spasms. 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 Cyclobenzaprine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Buprenorphine HCL 2 milligram sublingual tablet to treat chronic pain.  This is the diagnosis contained in the provided medical records.    The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication.  We received a reconsideration 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 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myfortic 180 milligram DR tablet to treat chronic kidney disease. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read 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 Myfortic was prescribed to treat chronic kidney disease and minimal change disease. However, the Medicare approved compendia do not support the use of this drug for the enrollees conditions. A physician reviewed your appeal and determined that the plan is not required to cover Myfortic.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Epolamine 1.3 percent patch prescribed as directed for low back pain, other intervertebral disc degeneration, and lumbar region, sacrococcygeal disorders, not elsewhere classified. 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 Epolamine to treat your low back pain, other intervertebral disc degeneration, and lumbar region, sacrococcygeal disorders, not elsewhere classified. However, the Medicare approved compendia do not support the use of this drug for your condition. As directedA physician reviewed your appeal and determined that the plan is not required to cover Diclofenac Epolamine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 10-milligram tablet to treat insomnia. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. This drug is considered a high-risk medication in older enrollees. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed, with support of medical records, the issues regarding this high-risk medication, and why alternative safer medications, in the plan's formulary, could not be used. 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 Wegovy 0.25 microgram/0.5 milliliter solution auto injector pen prescribed for weight loss. 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 you were prescribed Wegovy for the treatment of weight gain. We determined the plan is not required to cover Wegovy because it is excluded from coverage under Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexletol 180-milligram tablets prescribed for dyslipidemia. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates the prescriber ordered the drug at issue for the enrollees noted condition. 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 Xarelto 20 milligram tablets prescribed to treat the enrollees condition. The Part D plan denied the appeal 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.Xarelto is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jardiance 25-milligram tablets prescribed for type 2 diabetes mellitus without complications. 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.Jardiance is a brand drug on Tier 3 of the plans formulary. There are no other brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Sandostatin LAR Depot 200-microgram per milliliter intramuscular injection kit. 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 indicates that Sandostatin LAR Depot has been prescribed to reduce recurrent bleeding in an enrollee with angiodysplasias of the colon. 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 formulary exception request for Ingrezza 40 milligram capsules prescribed to treat the diagnosis of tardive dyskinesia. 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.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 Ingrezza 40 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fentanyl 100 micrograms per hour patch prescribed to treat an unknown diagnosis. 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 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 asked the prescriber to send us information regarding the enrollees condition. Specifically, we asked for medical records or other documentation (e.g., the diagnosis related to the requested drug and completion of the plans prior authorization document) to show why the enrollee needs this medication. We did not receive the requested documentation.The appeal request is for Fentanyl 100 micrograms per hour patch. Upon redetermination, the Part D plan denied the appeal request stating that the plans prior authorization criteria was not met. However, no medical records have been provided to determine if this enrollee has met the criteria for a medically acceptable indication per the approved Medicare compendia.A physician reviewed your appeal and determined that the plan is not required to cover Fentanyl 100 micrograms per hour patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Linzess 290 microgram capsules. 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. Linzess 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. 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. The drug will continue to be covered at the Tier 3 copay.