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

At issue is Pamasone 1%/1% cream prescribed for Behcets disease. 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 record shows the drug at issue is identified as a less than effective Drug Efficacy Study Implementation drug on the Medicare website.We determined that the plan is not required to cover Pamasone. Medicare Part D does not cover less than effective Drug Efficacy Study Implementation drugs. If the enrollee purchases drugs that are excluded, the enrollee must pay for them out-of-pocket. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Sodium 1% gel prescribed for rheumatoid arthritis. 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 indicates the prescriber ordered Diclofenac Sodium 1% gel for rheumatoid arthritis. However, the Medicare approved compendia do not support the use of this drug, in 1% gel form, for the enrollees condition. A physician reviewed the appeal and determined that the plan is not required to cover Diclofenac Sodium.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Buprenorphine Hydrochloride 2 milligram sublingual tablets prescribed for chronic pain and opioid dependence. 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 Levsin 0.125 milligram sublingual tablets prescribed for dyskinesia of esophagus. 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 not Food and Drug Administration approved. 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 Lidocaine 5% patch prescribed for low rib pain. 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 requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support a covered diagnosis and to indicate the enrollee met the plans coverage criteria. However, we did not receive the requested information.The submitted documentation indicates the prescriber ordered Lidocaine 5% patch for low rib pain. 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 Dexcom G6 sensor, receiver, and transmitter continuous glucose monitoring system prescribed to monitor an enrollee with diabetes. 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.Supplies for testing and monitoring blood glucose levels are not considered Part D drugs and may be covered under the Medicare Part B Durable Medical Equipment benefit. We have determined that the plan is not required to cover Dexcom G6 sensor, receiver, and transmitter continuous glucose monitoring system.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Guanfacine Hydrochloride 1 milligram tablets prescribed for attention deficit hyperactivity disorder. 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 indicates the prescriber ordered Guanfacine Hydrochloride for autistic disorder with attention deficit hyperactivity disorder in an adult. 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 Guanfacine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Farxiga 10 milligram tablets prescribed for type 2 diabetes mellitus. 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.We asked the prescriber to send additional information. Specifically, we requested medical records and 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 Farxiga.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Lynparza 100 milligram tablets prescribed for the treatment of pleomorphic sarcoma with positive BRCA VUS and BRIP1 mutations. The Part D plan denied the request. 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 Medicare-approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for treatment of the noted condition. The submitted documentation does not include any peer-reviewed, clinically relevant medical literature from an approved journal to support this appeal. Therefore, the requested drug is being prescribed for a non-medically accepted indication as defined by Medicare. As such, an exceptions request based on medical necessity cannot be considered because the requested drug does not meet the definition of a Medicare Part D drug. A physician reviewed the appeal and determined that the plan is not required to cover the Lynparza.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Eszopiclone 3 milligram tablets. The Part D plan denied the request because there was insufficient documentation to determine if the plans prior authorization requirements were 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. The available documentation does not include the enrollees diagnosis. During this review, a request was submitted to the prescriber to provide the diagnosis, to address the plans prior authorization requirements, and to provide supporting medical records. The prescriber did not respond to the request. Without a diagnosis, it cannot be determined if the drug is being prescribed for a medically accepted indication outlined in the Medicare approved compendia. 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 Lubiprostone 24 microgram capsules prescribed for chronic idiopathic constipation. 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.We asked the prescriber to send additional information. Specifically, we requested medical records and 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 Lubiprostone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Levalbuterol Tartrate HFA 45 microgram per actuation aerosol inhaler. The Part D plan denied the request for coverage because the medication was being used for a non-medically accepted indication. 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 diagnosis initially provided to the Part D plan is chronic graft-versus-host disease secondary to cutaneous T-cell lymphoma. However, the Medicare approved compendia do not contain any citations to support the use of Levalbuterol Tartrate for the treatment of this condition.At reconsideration, the diagnosis has been changed to bronchiolitis. However, the available medical records do not include this diagnosis and no additional medical records have been submitted to confirm the diagnosis. Therefore, there is insufficient evidence to determine if the requested drug is being prescribed for a medically accepted indication. As such, the requested drug is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nadolol 40 milligram tablets prescribed for hypertension. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We asked the prescriber to send additional information. Specifically, we requested medical records and 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 Nadolol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Aimovig 70 milligram per milliliter subcutaneous injection pen prescribed for the treatment of migraines. 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 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 Fexofenadine Hydrochloride 180 milligram tablets prescribed for an unknown condition. 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. Fexofenadine Hydrochloride is not included in the plans formulary. The documentation does not include any medical records from the prescriber. A request was submitted to the prescriber to provide a diagnosis and supporting medical records and to address the alternative medications included in the plans formulary to treat the enrollees condition. A reply from the prescriber was not received. Without a diagnosis it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested 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 Otezla 30 milligram tablets prescribed to treat an enrollee with plaque psoriasis. 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 records submitted at the reconsideration level.The medical records provided show the doctor prescribed Otezla 30 milligram tablets to treat plaque psoriasis. The enrollees plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed the appeal and determined that the plan is not required to cover Otezla 30 milligram tablets as the plans prior authorization criteria was not met. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch prescribed for chronic pain. 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 indicates the prescriber ordered Lidocaine 5% patch for chronic pain. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed the appeal and determined that the plan is not required to cover Lidocaine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Mycophenolate Mofetil 500 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 Mycophenolate Mofetil has been prescribed for the treatment of relapsing and remitting acquired thrombotic thrombocytopenia purpura. 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 tiering exception request for Myrbetriq extended-release 50 milligram tablets.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.Myrbetriq is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition 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 grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sulfatrim Pediatric 200 milligram/5 milliliter suspension prescribed for urinary tract infection. 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 record shows the manufacturer of the drug at issue, Pharm Assoc, does not participate in the Medicare Gap Discount Program. Payment cannot be allowed for a drug whose manufacturer does not participate in the Medicare Gap Discount Program.We determined that the plan is not required to cover the drug at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trelegy Ellipta 100-62.5 micrograms blister with device. 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.Trelegy Ellipta is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition 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 grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anoro Ellipta 62.5-25 micrograms inhaler to treat an enrollee with chronic obstructive pulmonary disease. 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.Anoro Ellipta is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. 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 Anoro Ellipta 62.5-25 micrograms inhaler.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azasite 1% eye drops prescribed to treat an enrollee with Meibomian gland dysfunction. The Part D plan denied the formulary exception 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.Upon redetermination, the Part D plan denied the appeal request stating that the formulary exception criteria was not satisfied. The documentation shows the doctor prescribed Azasite 1% eye drops to treat Meibomian gland dysfunction. 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 your appeal and determined that the plan is not required to cover Azasite 1% eye drops.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Nuedexta 20-10 milligram capsules prescribed to treat an enrollee with pseudobulbar affect. 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 records submitted at the reconsideration level.The medical records show the doctor prescribed Nuedexta 20-10 milligram capsules to treat pseudobulbar affect. DRUGDEX, a Medicare approved compendium shows pseudobulbar affect is a medically accepted indication for the use of the requested drug. The enrollees plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. According to the documentation, the physician has diagnosed the enrollee with brain injury with dementia leading to pseudobulbar affect. It is also notes the enrollee has a history of a stroke. Therefore, medical records provided support the enrollee has satisfied the plan's coverage criteria.A physician reviewed the appeal and determined that the plan is required to cover Nuedexta 20-10 milligram capsules as the plans prior authorization criteria has been satisfied. The physician reviewer also determined that an exception to the plans prior authorization requirements can be granted at this time.