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

At issue is Sildenafil 20-milligram tablet to treat pulmonary hypertension due to left heart disease (World Health Organization Group 2). 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 documentation shows your doctor prescribed Sildenafil to treat your pulmonary hypertension due to left heart disease (World Health Organization Group 2). 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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dalfampridine 10 milligram extended release tablets prescribed for downbeat nystagmus. 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 shows the prescriber originally ordered Dalfampridine for Lyme disease. The diagnosis was corrected to downbeat nystagmus.  This diagnosis is supported by the submitted medical records.  However, the 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 Dalfampridine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Topiramate 100 milligram tablets prescribed for obesity. 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 determined that the plan is not required to cover Topiramate because it was prescribed for weight loss. Drugs to treat anorexia, weight loss, or weight gain are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Quetiapine Fumarate 25 milligram tablet for late onset Alzheimers 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 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 Quetiapine Fumarate was prescribed to treat late onset Alzheimers disease. 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 Quetiapine Fumarate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xolair 150 milligram/milliliter solution prefilled syringe prescribed as directed for moderate persistent asthma. 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 Xolair to treat your moderate persistent asthma. 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 Xolair.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Lidocaine-Prilocaine 2.5/2.5% cream prescribed 30 grams per 30 days for diffuse large B-cell lymphoma. 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 Lidocaine-Prilocaine cream was prescribed to treat diffuse large B-cell lymphoma. However, the documentation does not support why an exception to the plans quantity limit is medically necessary. A physician reviewed your appeal and determined that the plan is not required to cover the Lidocaine-Prilocaine, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Velphoro 500 milligram chewable tablets prescribed for hyperphosphatemia in an enrollee on dialysis. 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 drug at issue is related to the enrollees end-stage renal disease. This is eligible for coverage under Part B. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligram tablets prescribed for gas and bloating due to small intestinal bacterial overgrowth. 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 prescriber indicated the enrollee has a diagnosis of irritable bowel syndrome with diarrhea. However, the submitted documentation shows the prescriber ordered Xifaxan for gas and bloating in an enrollee with a history of small intestinal bacterial overgrowth. 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 Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Promethazine Hydrochloride 25 milligram suppository prescribed as directed for nausea and vomiting. 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 Promethazine Hydrochloride to treat your nausea and vomiting. 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 Promethazine Hydrochloride suppository.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mesalamine 1.2 gram delayed release 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. Mesalamine is a generic drug on Tier 4 of the plans formulary. Your doctor did not address why all drugs/doses available on the lower tiers of your plans formulary would not work for you. 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 Gamunex-C 20 grams/200 milliliter solution prescribed for immune necrotizing myopathy. 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 submitted documentation shows the prescriber ordered Gamunex-C for immune necrotizing myopathy. The Medicare approved compendia do not support the use of this biologic for the enrollees condition. A physician reviewed the appeal and determined that the plan is not required to cover Gamunex-C.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Cinacalcet Hydrochloride 60 milligram tablet prescribed daily for the treatment of secondary hyperparathyroidism. 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. According to Medicare rules, the requested drug cannot be approved for separate payment under Part D when it's for treatment on a patient who is receiving dialysis. Medicare records show the enrollee is actively receiving dialysis. Therefore, the Cinacalcet Hydrochloride must be billed by the renal dialysis facility. We determined that the plan is not required to cover the Cinacalcet Hydrochloride. Please submit your request for this drug through the dialysis provider.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Evenity 105 milligram/1.17 milliliter prefilled syringe prescribed for osteoporosis. 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 has prescribed Evenity to treat osteoporosis and the documents support the drug will be administered in the prescribers office. 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 has not submitted medical evidence as to why all other alternatives on the plans formulary would not work.A physician reviewed your appeal and determined that the plan is not required to cover Evenity prefilled syringe.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydroxyzine Hydrochloride 10 milligram tablet prescribed for anxiety disorder, 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 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 requested additional information from the prescriber but did not get a response. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The enrollee has not satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Hydroxyzine Hydrochloride. 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 a tiering exception request for Trelegy Ellipta 100 microgram/1 Actuation-62.5 microgram/1 Actuation-25 microgram/1 Actuation inhalation powder to treat the enrollees condition. 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.Trelegy Ellipta is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception. Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch prescribed to treat an enrollee with neuropathy. 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.We asked the prescriber to send us information regarding the enrollees condition and to complete the prior authorization documentation. We also asked for medical records or other documentation to show why the enrollee needs this medication. We did not receive the requested documentation.Upon redetermination, the Part D plan denied the appeal request stating that the provided diagnoses (low back pain and unspecified osteoarthritis of unspecified site) were not medically accepted indications by Medicare approved compendia. On reconsideration, the prescriber shows Lidocaine 5% patch is prescribed to treat neuropathy. The prior authorization documentation for the requested drug was not submitted. In addition, there were no medical records provided to support that the enrollee has met the criteria for a medically accepted indication per the approved Medicare compendia.A physician reviewed the appeal and determined that the plan is not required to cover Lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyanocobalamin 1000 microgram solution prescribed for vitamin B12 deficiency anemia. 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 determined that the plan is not required to cover Cyanocobalamin because it is a prescription vitamin product. Drugs prescribed for prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Interferon alpha 2b solution 1,000,000 units/milliliter. 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 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 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 Incruse Ellipta 62.5 microgram/inhalation prescribed for chronic obstructive pulmonary disease. 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. Incruse Ellipta 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 Humalog Solution 100 unit/milliliter prescribed for type II diabetes mellitus with diabetic 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. We requested additional information from the prescriber but did not receive the information requested. 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 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 Humalog Solution.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Levalbuterol-HCL 0.63 milligram/3 milliliter ampule prescribed for the treatment of asthma. The Part D plan denied the enrollees 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 Levalbuterol-HCL is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover the Levalbuterol-HCL. Please consider submitting this request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lioresal 40 milligram/20 milliliter infusion kit prescribed for spasticity associated with cerebral palsy. 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 drug at issue is for use in an infusion pump in the enrollees home. This is eligible for coverage under Part B. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: 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 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 Butalbital/Acetaminophen/Caffeine 50-325-40-milligram tablet to treat unspecified headaches. 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 the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested compounded drug Versabase cream prescribed for specified disorders of adrenal gland and primary ovarian failure. 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, Progesterone micronized powder, and Estriol micronized powder do not meet the definition of Part D drugs. We reviewed Food and Drug Administration (FDA)-approved sources for the drugs classification or determined from other available resources that the drugs are bulk powders and therefore, not eligible for Part D coverage. We determined that the plan is not required to cover the compounded drug Versabase cream. 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 a request for coverage of Azopt 10 milligram/milliliter ophthalmic suspension prescribed for primary open-angle glaucoma. 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. 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 Azopt.