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

At issue is Hydroxyzine Hydrochloride 25 milligrams tablets prescribed to treat dementia. 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 for clarification of the enrollees diagnosis and medical records or other documentation to show why this medication was needed. We did not receive the requested documentation.The appeal request is for Hydroxyzine Hydrochloride 25 milligrams tablets. Upon redetermination, the Part D plan denied the appeal request stating that the provided diagnosis (dementia) is a non-medically accepted indication.  The clinic note dated April 9, 2021, shows a history of unspecified anxiety state with onset of January 2013. However, no additional medical records have been provided to clarify the enrollees diagnosis. The QIC is unable to determine if the enrollees condition is a medically-accepted indication to support the use of the requested drug.A physician reviewed the appeal and determined that the plan is not required to cover Hydroxyzine Hydrochloride 25 milligrams tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Epclusa 400-100 milligram tablet prescribed for chronic viral hepatitis C, genotype 3. 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 all documentation submitted. This includes any information submitted at the reconsideration level. The documentation includes records supporting hepatitis C, genotype 3 and the prescriber indicates the enrollee will be taking this drug in addition to weight based Ribavirin. However, there is no evidence of decompensated cirrhosis which would support a medically accepted indication for this drug in combination with Ribavirin. Medicare approved compendia do not support the use of the requested drug for the enrollees condition.  A physician reviewed your appeal and determined that the plan is not required to cover Epclusa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ibrance 125 milligram tablets prescribed for metastatic breast cancer, triple negative status. 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 Ibrance for metastatic breast cancer, triple negative status. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. There are no Medicare accepted journal articles to support the use of the drug 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 Xifaxan 550-milligram tablet to treat mixed irritable bowel syndrome, abdominal distension (gaseous), and constipation. 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 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 Xifaxan to treat your mixed irritable bowel syndrome. 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 Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vumerity DR 231 milligram capsule prescribed for multiple sclerosis. 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. This medication is not on your plan's list of medications. The prescriber has not given a clear and valid medical reason why all medications required by the plan, on that list, did not work for you. This reason has to be in the medical record with details of when you tried those medications. The reason the medications on the formulary won't work or could cause you harm have to be stated. Why the other medications required by the plan will not work must be discussed. Therefore, an exception to the plans formulary coverage criteria is not supported. A physician reviewed your appeal and determined that the plan is not required to cover Vumerity.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyanocobalamin 1000 microgram/milliliter solution prescribed for Crohns 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.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 Auunvi-Q 0.3-milligram/0.3-milliliter to treat bee allergy and bee pollen. 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 Auvi-Q.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Omnipod Dash insulin pump therapy 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.This drug is provided by the plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are 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 Oxycontin 20-milligram Extended Release 12-Hour Abuse-Deterrent tablet to treat chronic severe pain. 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. Xtampza ER is a formulary drug with the same active ingredients, has been tried, but not at maximal dosages in order to assess efficacy. 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

At issue is Cyanocobalamin 1000 microgram/milliliter solution prescribed for anemia falciforme. 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 Megestrol Acetate 625 milligram/5 milliliter suspension prescribed to promote weight gain in a cancer patient. 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 Megestrol Acetate because it was prescribed for weight gain. 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

The enrollee requested Freestyle Libre 14 Day Sensor prescribed for diabetes. 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 determined that the plan is not required to cover the Freestyle Libre Sensor because it is not considered a medical supply directly associated with the injection of insulin. Although, this supply is not covered under Part D, it may be covered under Part B. Please submit your request to Medicare Part B. This decision does not address the medical necessity or appropriateness of the supply. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrocodone Polistirex/Chlorpheniramine Polistirex 10.8 milligram/5 milliliter suspension prescribed for uncontrollable cough. 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 Hydrocodone Polistirex/Chlorpheniramine Polistirex  because it was prescribed for a cough. Drugs prescribed for symptomatic relief of cough and colds 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 Lidocaine Patch 5% prescribed for polyneuropathy in diseases classified elsewhere. 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 support Lidocaine Patch 5% is prescribed for traumatic injury of knee without tenderness or effusion. 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 Lidocaine Patch 5%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sumatriptan 100-milligram tablet 9-tablets/30-days to treat migraine unspecified, intractable with status migrainosus. 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 send us medical records, answers related to the quantity ordered, and a prescriber statement. However, we did not receive the documentation.The plan limits the amount of Sumatriptan to 8-tablets/30-days. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the condition or would be likely to cause harm. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that quantity limit criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a compound containing Diphenhydramine, Dexamethasone, Nystatin, and Tetracycline. 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 also researched Medicare systems and reviewed the enrollment data available.The QIC notes this drug is a compounded drug. Therefore, we reviewed each ingredient individually.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested. Without a diagnosis it cannot be established that Dexamethasone is being prescribed for a medically accepted indication. As such, the Dexamethasone does not satisfy the definition of a Medicare Part D drug. 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 reimburse Dexamethasone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a compound containing Diphenhydramine, Dexamethasone, Nystatin, and Tetracycline. 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 also researched Medicare systems and reviewed the enrollment data available.The QIC notes this drug is a compounded drug. Therefore, we reviewed each ingredient individually.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested. Without a diagnosis it cannot be established that Diphenhydramine is being prescribed for a medically accepted indication. As such, the Diphenhydramine does not satisfy the definition of a Medicare Part D drug. 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 reimburse Diphenhydramine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a compound containing Diphenhydramine, Dexamethasone, Nystatin, and Tetracycline. 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 also researched Medicare systems and reviewed the enrollment data available.The QIC notes this drug is a compounded drug. Therefore, we reviewed each ingredient individually.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested. Without a diagnosis it cannot be established that Nystatin is being prescribed for a medically accepted indication. As such, the Nystatin does not satisfy the definition of a Medicare Part D drug. 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 reimburse Nystatin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a compound containing Diphenhydramine, Dexamethasone, Nystatin, and Tetracycline HCL. 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 also researched Medicare systems and reviewed the enrollment data available.The QIC notes this drug is a compounded drug. Therefore, we reviewed each ingredient individually.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested. Without a diagnosis it cannot be established that Tetracycline HCL is being prescribed for a medically accepted indication. As such, the Tetracycline HCL does not satisfy the definition of a Medicare Part D drug. 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 reimburse Tetracycline HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyvanse 40 milligram capsules prescribed for moderate major depression. 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 Vyvanse for moderate major depression. On appeal, the prescriber indicated the diagnosis should be attention deficit hyperactivity disorder; however, the medical records indicate the drug at issue was prescribed for moderate major depression. 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

The enrollee requested Shingrix 50/0.5 milliliter injection prescribed for vaccination. 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 plan submitted documentation that shows the enrollee was still in the deductible stage for part of the cost for this drug and entered the initial stage for the remaining amount. You are responsible for the full cost of covered drugs until the deductible amount is satisfied. After the deductible was met, the plan calculated reimbursement based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the out-of-network(physicians office) charged you. We determined the Shingrix was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trulance 3-milligram tablet to treat opioid induced constipation. 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 Trulance to treat your opioid induced constipation. However, the Medicare approved compendia do not support the use of this drug for your condition. It is noted that the physician has cancelled this drug.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 Gilotrif 20 milligram tablet prescribed for malignant neoplasm of thyroid gland. 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 Gilotrif 20 milligram tablets were prescribed for metastatic papillary thyroid cancer. However, the Medicare approved compendia do not support the use of this drug for this condition. The prescriber submitted three articles that are not Medicare approved journals and all studies submitted had been completed in cancer cell lines with results that had not been established in human subjects. A physician reviewed your appeal and determined that the plan is not required to cover Gilotrif.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sirolimus 1 milligram tablet prescribed daily for a history of kidney transplant. 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 record shows the enrollee received Sirolimus following a Medicare covered kidney transplant on March 18, 2010. Therefore, the drugs are eligible for coverage under Medicare Part B and excluded from Part D coverage.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.