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

At issue is Botox 200-unit solution reconstituted prescribed as directed for chronic migraine.. 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 Botox.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lumakras 120 milligram tablets prescribed for metastatic colon cancer, KRAS mutated. 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 Lumakras for metastatic colon cancer, KRAS mutated. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. There were no Medicare approved journal articles submitted to support the use of Lumakras 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 Tadalafil 10 milligram tablets prescribed for secondary Raynauds syndrome. 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 Tadalafil because it is an erectile dysfunction drug prescribed for an off-label usage. Sexual or erectile dysfunction drugs prescribed for off-label uses 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 Pimecrolimus 1% cream prescribed for unspecified rash. 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 Pimecrolimus for unspecified rash. 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 Hydrocodone Polistirex/Chlorphenirame Polistirex 10-8/5 milliliter suspension prescribed for bronchitis related to COVID 19. 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 also researched Medicare regulations and Medicare approved compendia. The prescriber indicates they are requesting Hydrocodone Polistirex/Chlorphenirame Polistirex 10-8/5 milliliter suspension to treat bronchitis related to COVID 19.  Drugs prescribed for the symptomatic treatment of cough and colds are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.A physician reviewed your appeal and determined that the plan is not required to cover Hydrocodone Polistirex/Chlorphenirame Polistirex 10-8/5 milliliter suspension.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nuplazid 34 milligram capsules prescribed for Lewy body dementia with behavioral disturbance. 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 Nuplazid for Lewy body dementia with behavioral disturbance. 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 Ajovy 225 milligram/1.5 milliliter syringe prescribed as directed for migraine prophylaxis. 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 Ajovy.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synthroid 75 microgram tablets prescribed to take one tablet, by mouth, once a day to treat hypothyroidism. 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. The reconsideration appeal letter states, My patient has tried and failed these medications (alternative formulary drugs). However, the prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported.A physician reviewed the appeal and determined that the plan is not required to cover Synthroid 75 microgram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gammaplex Solution 20 gram/200 milliliter prescribed as directed for other spondylosis with radiculopathy, 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 Gammaplex Solution to treat your other spondylosis with radiculopathy, 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 Gammaplex Solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide EC 3 mg DR capsules 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. Budesonide EC is a generic drug on Tier 4 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

The enrollee requested Tetanus-Diphtheria vaccine prescribed for vaccination. The Part D 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.The record shows the enrollee was administered the Tetanus-Diphtheria vaccine at their physicians office. Payment for vaccines including administration fee is required up front when provided at an out of network pharmacy or provider's office. You will be reimbursed the amount you paid less any deductible, copayment or coinsurance and less the amount the physician charges and the plans approved amount. The enrollee submitted documentation that includes a physicians statement. However, there is no receipt showing the enrollee paid the full amount of the vaccine and administration fee, as required by the plans Evidence of Coverage, regarding vaccine administration from a physician or provider's office. Therefore, we determined that the plan is not required to reimburse the enrollee for the vaccine and administration fee at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rhopressa Ophthalmic 0.02% solution prescribed for low tension glaucoma, right eye, moderate stage. 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 prescriber does not indicate 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 Rhopressa.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Hylatopic Plus lotion prescribed daily for treatment of atopic dermatitis. The Part D 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. We determined that the plan is not required to cover the Hylatopic Plus lotion. According to Microdex, Hylatopic Plus lotion has not been found by the Food and Drug Administration to be safe and effective; and the drug product label has not been approved.  Therefore, the drug is excluded from coverage under Medicare Part D. This decision does not concern 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 Otezla 28 day Starter Pack  prescribed as directed for psoriasis. 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 Otezla 28 day Starter Pack.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Ocaliva 5 milligram tablet prescribed for primary biliary cirrhosis. 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. Your prescriber indicates they prescribed Ocaliva 5 milligram tablet for primary biliary cirrhosis. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation indicates there are claims showing continuous use of Ursodiol and both a pre-treatment and post-treatment alkaline phosphatase are submitted that support a decrease in the laboratory result since beginning the drug. The plan's coverage criteria has been met.  A physician reviewed your appeal and determined that the plan is required to cover Ocaliva 5 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch prescribed to treat hand, thoracic, and lumbar pain. 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. Specifically, we asked the prescriber to complete the prior authorization document to show why the enrollee needs this medication. We did not receive the requested documentation.The doctor prescribed Lidocaine 5% patch to treat hand, thoracic, and lumbar pain. The prior authorization documentation for the requested drug was not submitted. In addition, the medical records provided fail to support that the enrollee has met the criteria for a medically acceptable 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 Entresto 24-26 milligram tablet prescribed twice daily for congestive heart failure. 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. Entresto 24-26 milligram tablet 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 Reclast 5 milligram/100 milliliter solution prescribed for postmenopausal osteoporosis. The case was auto-forwarded by the plan.  We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We requested additional information from the prescriber. Specifically, we requested a prescriber statement to support all formulary alternatives were tried and failed. However, we did not receive the requested information.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 Reclast.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Atropine Sulfate 0.4 milligram/milliliter injection prescribed daily for treatment of nausea from malignant neoplasm of colon. The Part D 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. We determined that the plan is not required to cover the Atropine Sulfate injection. According to Microdex, Atropine Sulfate injection has not been found by the Food and Drug Administration to be safe and effective; and the drug product label has not been approved. Therefore, the drug is excluded from coverage under Medicare Part D. This decision does not concern 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 Pregabalin 50 milligram tablet. At initial determination and redetermination the diagnosis of radiculopathy, cervical region was given. 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.At reconsideration a diagnosis of neuropathic pain due to spinal cord injury was given. The medical records provided do not support this diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. A physician reviewed your appeal and determined that the plan is not required to cover Pregabalin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Epclusa 400 milligram-100 milligram tablets prescribed for chronic hepatitis C virus infection. The case was auto-forwarded by the plan.  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 on hand includes medical records and a supporting statement. The documentation does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 1.62% gel prescribed one pump every day for testicular hypofunction and hypogonadotropic hypogonadism. 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. 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 that other drugs on the plans formulary would not work. A physician reviewed the appeal and determined that the plan is not required to cover Testosterone 1.62% gel.
Appeal type: Prescription Drug
Decision: Favorable

You requested Tacrolimus 1 milligram capsule prescribed for a kidney transplant recipient. 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 had a kidney transplant on November 17, 2020, while covered under a private insurance and it was not covered by Medicare. This drug is eligible under Part D drug benefits. Medicare approved compendia supports the use of this drug for the reported condition.  A physician reviewed your appeal and determined that the plan is required to cover Tacrolimus 1 milligram capsule.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ipratropium Bromide 0.02% nebulizer solution. 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 a nebulizer 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 Ondansetron Hydrochloride 4 milligram tablets. 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 does not include medical records or evidence of a prescribed diagnosis. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Metopirone 250 milligram capsule prescribed for metastatic pancreatic neuroendrocrine tumor. 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, drugs used as an integral part of a procedure that is a diagnostic or therapeutic service are excluded from coverage under Part D. The record shows Metopirone was used as a diagnostic service. Therefore, it is excluded from coverage under the Part D benefit. Therefore, we determined that the Part D plan is not required to cover the Metopirone. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.