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

You requested compounded drug Methylcobalamin 50,000 microgram/10 milliliter injection prescribed for unknown diagnosis.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 QIC notes this drug is a compounded drug. Therefore, we reviewed each ingredient individually.Methylcobalamin powder:Medicare Part D does not cover non-prescription drugs. We reviewed Food and Drug Administration (FDA)-approved sources for the drugs classification or determined from other available resources that the drug is on the list of drugs that are excluded from coverage under Medicare Part D. Therefore, the Methylcobalamin powder ingredient is not eligible for Part D coverage. Sodium Acetate ANH.USP and Sodium Chloride USP granul:Medicare Part D does not cover non-prescription drugs. We reviewed Food and Drug Administration (FDA)-approved sources for the drugs classification or determined from other available resources that the drugs are non-prescription or over-the-counter (OTC) drugs. Therefore, the Sodium Acetate and Sodium Chloride ingredients are not eligible for Part D coverage. The plan is not required to cover/ provide reimbursement for the compounded drug Methylcobalamin injection. This decision does not address the medical necessity of this drug. It only means that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methenamine Hippurate 1 gram tablet, a quantity of 60 tablets per 30 days. 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 records submitted at the reconsideration level. The documentation supports your payment for Methenamine Hippurate for an amount of $35.06. You are requesting this amount to be applied to your deductible. The documentation indicates that you were still in the deductible stage of the Part D benefit when you purchased the Methenamine Hippurate. Therefore, no reimbursement is required by the plan and the amount you paid will be applied to your deductible.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Stelara 90 milligram/milliliter syringe 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. This drug is included on Tier 5 of the plans formulary. This tier is identified as a Specialty Tier. The plan is not required to grant a tiering exception for drugs available on their Specialty Tier. Therefore, a tiering exception cannot be considered.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ondansetron 4 milligram disintegrating tablet, prescribed for vertigo and nausea. 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 Ondansetron to treat your vertigo and nausea. 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 Ondansetron.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hyoscyamine Sulfate 0.125-milligram sublingual tablets prescribed as directed. 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 record shows the physician prescribed Hyoscyamine Sulfate. Hyoscyamine Sulfate has not been approved by the Food and Drug Administration. Non-Food and Drug Administration approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.We  determined that the plan is not required to cover Hyoscyamine Sulfate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Otezla 30 milligram tablets prescribed to treat recurrent aphthous ulcers. 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 Otezla 30 milligram tablets to treat recurrent aphthous ulcers without the diagnosis of Behcets syndrome. 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 Otezla 30 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vimpat 100 milligram oral tablet. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.This drug is included on Tier 5 of the plans formulary. This tier is identified as a Specialty Tier. The plan is not required to grant a tiering exception for drugs available on their Specialty Tier. Therefore, a tiering exception cannot be considered.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Androgel 1.62% Gel Pump to treat hypogonadism, male 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 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.  This drug requires very specific criteria to be met in order to be considered a medically accepted indication. The records provided do not indicate that male hypogonadism (testicular hypofunction) is the result of primary or hypogonadatropic hypogonadism. In addition, per the compendia, The safety and efficacy of testosterone therapy have not been established in men with late-onset (age-related) hypogonadism.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 Praluent 150 milligram/milliliter Solution Auto Injector 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. Praluent is a biological product drug on Tier 3 of the plans formulary. There are no biological product 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: Favorable

At issue is a request for coverage of Xhance 93 microgram per actuation nasal spray prescribed for chronic sinusitis with nasal polyps. 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 documentation satisfies the plans coverage criteria. The prescriber clarified the medical history in the request for reconsideration.  Medical records from date of service June 2, 2021 were provided which documented that the enrollee tried and failed Fluticasone and had an adverse reaction with Qnasl.  A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine Hydrochloride 10 milligram tablet prescribed one tablet three time daily for chronic, intermittent muscle spasms. 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 Cyclobenzaprine Hydrochloride to treat your chronic, intermittent muscle spasms. 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 Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Adderall Extended Release 30-milligram Capsule Extended Release 24-Hour to treat attention deficit disorder without mention hyperactivity. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 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.Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dayvigo 10 milligram tablets prescribed for insomnia. 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.A request was submitted to the prescriber to provide a diagnosis, to address the nonformulary criteria, and to provide supporting medical records.  A reply from the prescriber was not received.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 your appeal and determined that the plan is not required to cover Dayvigo.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Orgovyx 120 milligram tablets prescribed as directed for metastatic prostate cancer. 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 the doctor prescribed Orgovyx to treat metastatic prostate cancer. The enrollee has been treated for prostate cancer with Eligard, Yonsa, and Prednisone; the enrollee has been responding to this treatment regimen well and is without complaints. The prescriber states that they are requesting a change in the treatment regimen to Orgovyx, Yonsa, and Prednisone, due to the enrollees extensive cardiac history. However, the medical records do not support that the enrollee has an extensive cardiac history. In summary, Orgovyx has not been prescribed as a single agent to treat the enrollees metastatic prostate cancer. The Medicare approved compendia do not support the use of Orgovyx in combination with Yonsa and Prednisone for the treatment of the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Orgovyx.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Percocet 5-325 milligram tablet prescribed for lumbar intervertebral disc degeneration. 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 the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.We asked the prescriber to send us information regarding the enrollees condition and to provide supporting medical records. We also asked for attestations as to whether the enrollee is or is not opioid naive. However, we did not receive the documentation.The record shows the physician ordered Percocet for the enrollees lumbar intervertebral disc degeneration. However, the prescriber did not provide an attestation regarding the enrollees opioid status.A physician reviewed your appeal and determined that the plan is not required to cover the Percocet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synthroid 100 microgram tablets prescribed as directed. The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. Synthroid is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Epolamine 1.3% patch prescribed twice daily for low back pain and acute ankle pain due to minor strain. 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 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. We also asked for medical records or other documentation to show why the medication was needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. However, we did not receive the documentation.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 Diclofenac Epolamine 1.3% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue a request for coverage of Eliquis 5 milligram tablets prescribed for atrial fibrillation. 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. Eliquis is not included in the plans formulary. 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. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Megestrol Acetate 400 milligram per 10 milliliter oral suspension. 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 Megestrol Acetate has been prescribed for lack of appetite and weight loss due to dementia and a history of radiation to the throat. 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 conditions. Therefore, the drug is being prescribed for non-medically accepted indications 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 Megestrol Acetate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tresiba Flextouch U-100 100/milliliter insulin pen prescribed as directed for type 1 diabetes mellitus with hyperglycemia. 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 Tresiba Flextouch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue a request for coverage of Horizant ER 300 milligram extended release tablets prescribed for restless leg syndrome. 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. Horizant ER is not included in the plans formulary. 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. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Otezla Therapy Pack 10 and 20 and 30 milligram tablets prescribed to treat plaque 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 Therapy Pack 10 and 20 and 30 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cevimeline HCL 30 milligram capsules prescribed to treat xerostomia associated with Sjogrens syndrome. 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. 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 your appeal and determined that the plan is not required to cover Cevimeline HCL 30 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cyclobenzaprine Hydrochloride 5 milligram oral tablet prescribed daily for acute muscle spasms. 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 Cyclobenzaprine Hydrochloride to treat your acute muscle spasms related to a chronic condition. The prescriber stated on 6/1/2021 that the onset of the condition was 6/11/2020 and that the enrollee had 'chronic pain due to cancer.'  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 Cyclobenzaprine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Muro 128 Solution 5% Eye Solution prescribed for keratopathy (bullous aphakic) following cataract surgery, left eye. 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. Muro 128 Solution 5% Eye Solution is available over-the-counter. Non-prescription drugs are excluded from Medicare Part D drug benefits.A physician reviewed your appeal and determined that the plan is not required to cover Muro 128 Solution 5% Eye Solution.