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

At issue is Colesevelam 625 milligram tablets prescribed to treat diarrhea, unspecified.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 doctor prescribed Colesevelam 625 milligram tablets to treat diarrhea, unspecified. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed the appeal and determined that the plan is not required to allow payment or cover Colesevelam 625 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Estradiol 0.0375 milligram/24 hour patch prescribed for the enrollees condition. 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.We requested additional information from the prescriber. Specifically, we requested medical records and a supporting statement to indicate the enrollee had tried and failed all lower-tier medication. However, we did not receive the documentation.Estradiol is a generic drug on Tier 4 of the plans formulary. The prescriber did not submit a supporting statement to address why all the drugs available on the lower tiers of the plans formulary would not work. 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 Sildenafil Citrate, generic for Viagra, 100 milligram tablets to treat erectile dysfunction. 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 appeal request is for Sildenafil Citrate to treat sexual or erectile dysfunction. We determined that the plan is not required to cover Sildenafil Citrate. Medicare excludes certain drugs from Part D coverage. Sildenafil Citrate is an excluded drug when used to treat sexual or erectile dysfunction; or to treat a condition other than sexual or erectile dysfunction for which the drug has not been approved by the Food and Drug Administration. The record does not indicate that the plan provides supplemental coverage for Sildenafil Citrate. Therefore, the plan is not required to cover it. 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 Lidocaine 5% patches. 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 Lidocaine 5% patches have been prescribed for the treatment of osteoarthritis of the spine. 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. During this review, a request was sent to the prescriber to clarify the diagnosis.  However, the prescriber did not respond. Therefore, the available documentation supports that the requested 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 Methenamine Hippurate 1-gram tablet to treat 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.Methenamine Hippurate is a generic drug on Tier 3 of the plans formulary. The prescriber has not indicated if all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug. 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 a request for coverage of Privigen 10% (5 milligram per 50 milliliter) solution. The Part D plan denied the request stating that coverage for the drug would be available under Medicare Part B. 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 prescriber initially provided two diagnoses to the plan, chronic inflammatory demyelinating polyneuropathy and severe combined immunodeficiency with low T- and B-cell numbers. Severe combined immunodeficiency is a primary immunodeficiency and coverage for Privigen 10% when given for primary immune deficiency disease would be available under Medicare Part B.At reconsideration, the prescriber has noted that the enrollee is receiving Privigen 10% only for chronic inflammatory demyelinating polyneuropathy, which would be covered under Medicare Part D if all other requirements have been met. However, no medical records have been submitted to the plan or at reconsideration to confirm the enrollees diagnosis/diagnoses.During this review, a request was submitted to the prescriber to clarify the diagnosis/diagnoses and to provide supporting medical records. The prescriber did not submit any medical records and did not answer the submitted questions. Without any medical records to validate the enrollees condition, it cannot be determined if the requested drug is available for coverage under Medicare Part B or Medicare Part D. It also cannot be confirmed that the requested drug is being prescribed for a medically accepted indication as 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 Restasis 0.05% dropperette prescribed twice daily for dry eyes. 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 records 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 this medication was needed. We did not receive the documentation requested.The doctor prescribed Restasis 0.05% dropperette to treat the enrollees dry eyes. The 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 Restasis 0.05% dropperette. 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 Nuzyra 150 milligram tablet prescribed for mycobacterial fortuitum infection. 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 Nuzyra 150 milligram tablet was prescribed to treat mycobacterial fortuitum infection. 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 Nuzyra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cymbalta 40-milligram Capsule to treat persistent migraine aura without cerebral infarction, not intractable and migraine headache. 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 use of the requested drug to treat the provided diagnoses are off-label uses. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of these conditions. 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 Bromsite 0.075% Solution to treat capsular glaucoma. 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 use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.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 Octreotide Acetate 50 microgram per milliliter solution for injection. 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 Octreotide Acetate has been prescribed for the treatment of gastrointestinal bleeding secondary to multiple arteriovenous malformations and angiodysplasias. 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 Tadalafil 2.5 milligram tablet prescribed for erectile dysfunction. The Part D plan denied your request. We performed 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. We determined that the plan is not required to cover Tadalafil because it was used to treat sexual or erectile dysfunction. Drugs prescribed for the treatment of sexual or erectile dysfunction 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

The enrollee requested Shingrix 50/0.5 microgram injection prescribed for vaccination. 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 that you are enrolled in a primary insurance plan that is not Medicare Part D. The pharmacy should bill the prescription for Shingrix to the primary plan before billing Medicare Part D plan. The Medicare Part D Plan is not required to process the claim until after your primary insurance has processed it. We have determined that the plan is not required to allow coverage as secondary payer. You may resubmit your claim to your Part D plan once your primary insurance has processed it.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Otezla 10-20-30 milligram starter therapy pack tablets prescribed to treat psoriasis. 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 records submitted at the reconsideration level.The medical records show the doctor prescribed Otezla 10-20-30 milligram starter therapy pack tablets to treat 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 10-20-30 milligram starter therapy pack tablets, as the plans prior authorization requirements are not satisfied. 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 Clonazepam 0.5 milligram tablet prescribed for a 38 day supply to treat unspecified mood disorder and borderline personality disorder. The Part D plan denied a requested 38 day supply as it is only allowed per a 30 day supply.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 medical records indicate Clonazepam 0.5 milligram was prescribed to treat unspecified mood disorder and borderline personality disorder. 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 Clonazepam 0.5 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eszopiclone 2-milligram tablet for an unknown 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.We requested from your prescriber answers to prior authorization questions and medical records. We did not receive the requested documents.At reconsideration a diagnosis of chronic insomnia was given. No medical records were provided by the prescriber to support this diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. 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 Horizant extended release 300 milligram tablets to treat neuropathic pain not associated with 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 reviewed the case file and all documentation submitted. This includes any information submitted at the reconsideration level. The use of the requested drug to treat the provided diagnosis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.  A physician reviewed your appeal and determined that the plan is not required to cover Horizant extended release tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Baclofen 10 milligram tablets prescribed for bilateral blepharospasm. 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. Baclofen is a generic drug on Tier 3 of the plans formulary. There are no generic drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no generic drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligram tablet prescribed for abdominal bloating. 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 medical records show Xifaxan was prescribed to treat abdominal bloating. 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 a request for coverage of Armodafinil 250 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 Armodafinil has been prescribed for fatigue related to multiple sclerosis. 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 Eszopiclone 2-milligram tablet to treat insomnia. 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 asked your prescriber to submit a prescriber statement, answers to prior authorization questions, a list of non-high risk medications tried, alternative drugs tried and failed or contraindicated, and medical records. We did not receive the requested documents.The documentation does not satisfy the plans coverage criteria. The prescriber has not addressed, with support of medical records, the issues regarding this high-risk medication, and why alternative safer medications, in the plan's formulary, could not be used. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested NP Thyroid 90 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the request for reimbursement.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 submitted documentation that shows the enrollee was still in the deductible stage of the Part D benefit when the NP Thyroid was purchased. The plans Evidence of Coverage states that the enrollee is responsible for the full cost of covered drugs until the deductible amount is satisfied. We determined that the amount the enrollee paid was correctly applied to the deductible and additional reimbursement is not required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Finacea foam 15 percent prescribed as directed for rosacea. 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 Finacea foam.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Cephalexin 500 milligram capsule prescribed for unknown diagnosis. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we 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 enrollees daughters flexible spending account was used to purchase the Cephalexin at the pharmacy. There is no evidence that the insurance information was up-to-date or available to the pharmacy when the Cephalexin was purchased. Medicare rules state that plans are not required to reimburse an enrollee for drugs/supplies that were not purchased through the Part D plan. Therefore, the plan is not required to cover or provide reimbursement for Cephalexin.To pursue payment, please update your insurance information at the pharmacy where you purchased these drugs and ask to reprocess the claim through your Part D insurance without applying any discounts.