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

At issue is Oxycodone HCL 5 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows the enrollee requested the plan to provide reimbursement for the Oxycodone HCL. However, the enrollees provider was contacted and confirmed that the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the Oxycodone HCL. Please submit your request to Medicare Part A. 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 Thera-M tablet. 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 the enrollee requested the plan to provide reimbursement for Thera-M. According to Medicare rules, drugs that are considered over-the-counter are excluded from coverage under Part D. Thera-M is an over-the-counter medication. There is no evidence that the enrollee has supplemental coverage for the Thera-M. Therefore, we determined that the Part D plan is not required to cover or reimburse the enrollee for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Warfarin Sodium 5 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows the enrollee requested the plan to provide reimbursement for the Warfarin Sodium. However, the enrollees provider was contacted and confirmed that the enrollee was admitted to a hospital inpatient stay when the drugs were administered. According to Medicare rules, Part A pays for drugs received by an enrollee in an inpatient setting. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover or provide reimbursement for the Warfarin Sodium. Please submit your request to Medicare Part A. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Dronabinol 10 milligram capsule prescribed for nausea. 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 the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why you need this medication. We received the documentation and included it in our review.The documentation shows Dronabinol was prescribed to treat nausea. 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 Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement request for Numaqula Macular Package for dates of January 19, 2021, and April 14, 2021, to treat the enrollee with early macular degeneration. The Part D plan denied the appeal request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. The reimbursement request is for Numaqula Macular Package. The documentation provided for review fails to include a valid National Drug Code for the requested product. The National Drug Codes should be provided to verify with the Food and Drug Administration. Therefore, we have determined that the plan is not required to cover and provide reimbursement for Numaqula Macular Package for the dates of service noted above. 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 Mycophenolate Mofetil 250 milligram capsules prescribed to treat the enrollee with myocardial sarcoidosis. The Part D plan denied the appeal request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows the doctor prescribed Mycophenolate Mofetil 250 milligram capsules to treat myocardial sarcoidosis. 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 250 milligram capsules.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Gammagard Solution 5 gram/50 milliliter prescribed for chronic inflammatory demyelinating polyneuritis.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. Gammagard Solution is prescribed to treat chronic inflammatory demyelinating polyneuritis which is an orphan drug designation use per Medicare approved compendia. The records show the drug will be used in the home and therefore is a Part D eligible drug.  The plan noted that they intended to approve this request but the appeal was overdue and was therefore forwarded.A physician reviewed your appeal and determined that the plan is required to cover Gammagard.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Horizant ER 600 milligram extended release tablets prescribed for the treatment of restless leg syndrome. 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 a request for coverage of Opsumit 10 milligram tablets. 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 Opsumit has been prescribed for the treatment of pulmonary hypertension with right heart failure and combined pulmonary fibrosis and emphysema. 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 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 Lidocaine 5% patch prescribed to treat the enrollee with lumbar spinal stenosis with neurogenic pain. 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.We asked the prescriber to send us information regarding the enrollees condition. We also asked for additional documentation to show why the enrollee needs this medication. We did not receive the requested documentation.The appeal request is for Lidocaine 5% patch for the enrollees condition. It also notes that the enrollee reported back and hip pain. The Part D plan denied the appeal request stating that the plans authorization criteria was not satisfied. However, no additional documentation has been provided to determine if this enrollee has met the criteria for a medically acceptable indication per the approved Medicare compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked for reimbursement for a co-payment of Triamcinolone 0.1% in Sarna topical lotion. 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 information provided does not include a diagnosis and it was unable to be determined if the drug was prescribed for a medically accepted indication. We requested additional information from the prescriber including what the drug is used for and what all components are included in this compound drug but did not get a response.  A physician reviewed your appeal and determined that the plan is not required to reimburse the co-payment amount requested.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methotrexate 25 milligrams per milliliter vial for subcutaneous injection prescribed to treat the enrollee with primary Sjogrens syndrome, fibromyalgia, and arthralgia of multiple joints. 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 information submitted at the reconsideration level.The documentation shows the doctor prescribed Methotrexate 25 milligrams per milliliter vial for subcutaneous injection to treat primary Sjogrens syndrome, fibromyalgia, and arthralgia of multiple joints.. 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 Methotrexate 25 milligrams per milliliter vial.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone Gel 50 milligram/5 gram. 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. Testosterone Gel is a generic drug on Tier 3 of the plans formulary. There are no generic 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 Shingrix 50 microgram/0.5 milliliter suspension 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. Shingrix 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 Carvedilol 25 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the enrollees request for additional reimbursement.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The plan submitted documentation that shows the enrollee paid the required copay for the requested drug at an in-network pharmacy. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. In this case, documentation was provided showing the Medicare contracted price for the prescription was less than the copay for the tier 1 drug. The plan will only reimburse up to the contracted price of the drug and because the price was less than the enrollees copay, no additional reimbursement is due. We determined the plan calculated the enrollees copay correctly and is not required to offer additional reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lotemax 0.5 Suspension prescribed for preventative glaucoma, sarcoidosis, and keratopathy. 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. The drug 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 prescriber does not indicate why the other alternatives on the plans formulary would not work.A physician reviewed your appeal and determined that the plan is not required to cover Lotemax Suspension.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of a Freestyle Libre 2 Reader continuous glucose monitoring system prescribed for the management of diabetes mellitus. The Part D plan your 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.Continuous glucose monitors and related accessories are classified by the United States by the Food and Drug Administration (FDA) as medical devices. As such, they do not meet the definition of a Part D drug. Furthermore, continuous glucose monitors are durable medical equipment. Medicare rules state that Medicare Part B pays for the rental and purchase of durable medical equipment. Coverage under Part D is excluded for any drug or item for which payment would be available under Part B. Therefore, the continuous glucose monitor is not eligible for coverage under Medicare Part D, as it is classified as a medical device and does not meet the definition of a Part D drug. Additionally, being durable medical equipment, coverage for the device is available under Medicare Part B. This decision does not address the medical necessity or appropriateness of the requested item. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Quetiapine Fumarate 25 milligram tablets. The Part D plan denied the request because the plans prior authorization requirements were not met.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 Quetiapine Fumarate has been prescribed for the treatment of dementia with behavioral disturbance. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug for the treatment of the noted condition. On the contrary, it is noted in the Medicare approved compendium, American Hospital Formulary Service Drug Information (AHFS-DI), that the manufacturer states Quetiapine Fumarate is not approved for the treatment of dementia-related psychosis. As such, the requested drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. Since the drug is not eligible for coverage, the plans prior authorization requirements are not relevant to this review. 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 Stelara 90 milligram/milliliter syringe prescribed as directed for necrobiosis lipoidica, 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 Stelara to treat your necrobiosis lipoidica, not elsewhere classified. 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 Stelara.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Qutenza 8 percent kit prescribed as directed for hereditary and idiopathic neuropathy, unspecified. 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 Qutenza to treat your idiopathic neuropathy, unspecified. 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 Qutenza.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Xifaxan 550 milligram tablet prescribed for small intestinal bacterial overgrowth. 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 Xifaxan was prescribed to treat small intestinal bacterial overgrowth. 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 Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Clobetasol Propionate 0.05% foam prescribed for telogen effluvium. The Part D plan denied the request for the non-formulary drug. We received the case to perform 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. Clobetasol Propionate is prescribed for telogen effluvium. However, Medicare approved compendia do not support the use of this drug for this condition.  A physician reviewed your appeal and determined that the plan is not required to cover Clobetasol Propionate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Wegovy 0.25 milligrams per 0.5 milliliter pen injector prescribed to treat an enrollee with elevated body mass index. 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 enrollee was prescribed Wegovy 0.25 milligrams per 0.5 milliliter pen injector to treat the enrollees condition. We determined the plan is not required to cover Wegovy because it is excluded from coverage under Part D. 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 Xiidra 5 percent eye drops prescribed as directed for dry eyes. 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 Xiidra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Cinacalcet 30 milligram tablet prescribed for an unknown condition. 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 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 this medication. We did not receive the documentation requested.Without a diagnosis it cannot be established that Cinacalcet is being prescribed for a medically accepted indication.  As such, the requested drug does not satisfy the definition of a Medicare Part D drug.  Therefore, Cinacalcet is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover Cinacalcet.