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

At issue is Nuplazid 34-milligram capsule. At initial determination and redetermination the diagnosis of unspecified dementia without behavioral disturbance was given. 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.At reconsideration a diagnosis of Parkinsons disease was given. No medical records were provided by the prescriber to support this diagnosis. As such, the use of the requested drug to treat the provided diagnosis of unspecified dementia without behavioral disturbance 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 Esomeprazole Magnesium DR 40 milligram capsules to be taken twice daily, 60 capsules per 30 days. 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 Esomeprazole Magnesium DR has been prescribed for the treatment of gastroesophageal reflux disease. While the use of Esomeprazole Magnesium DR for the treatment of gastroesophageal reflux disease is a medically accepted indication outlined in the Medicare approved compendia, the maximum daily dose cited in the compendia is 40 milligrams. The daily dose requested by the prescriber is 80 milligrams, 40 milligrams to be taken twice daily. Therefore, the dose requested exceeds the dose cited in the Medicare approved compendia. As such, the Esomeprazole Magnesium DR at the requested dose is not supported by the Medicare approved compendia. 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

You requested Vosevi 400-100 milligram tablet prescribed for hepatitis C virus, genotype 3. 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 Vosevi 400-100 milligram tablet prescribed for hepatitis C virus, genotype 3. 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 Vosevi.
Appeal type: Prescription Drug
Decision: Unfavorable

Cyclobenzaprine Hydrochloride 10 milligram tablet was requested to treat the enrollees condition.  The Part D plan denied your request because medical necessity was not established.  As well, the requested drug has prior authorization criteria.  We received an expedited reconsideration request.We performed 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 prior authorization criteria, and to provide supporting medical records.  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 drug 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 cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Belbuca 750 microgram buccal film prescribed every 12 hours for chronic pain syndrome secondary to rheumatoid arthritis and fibromyalgia. The Part D plan did not make a decision.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. We received the documentation and included it in our review.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.A physician reviewed the appeal and determined that the plan is not required to cover Belbuca.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Modafinil 200 milligram tablet prescribed daily for daytime somnolence due to obstructive sleep apnea. 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 Modafinil to treat the enrollees daytime somnolence due to obstructive sleep apnea. Per the Medicare approved compendia, this is a medically accepted indication. However, 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 Modafinil. 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: Favorable

At issue is Febuxostat 80 milligram tablet prescribed to treat kidney stones. 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. The prescriber indicates that the enrollee has chronic kidney disease stage III, hyperuricemia with recurrent episodes of gout, diabetes mellitus type II, hypertension and nephrolithiasis. The prescriber submitted medical records that support the diagnoses of hyperuricemia and gout. The medical records also support that the enrollee had tried Allopurinol but it was not effective. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The plans prior authorization requirements were met.  A physician reviewed your appeal and determined that the plan is required to cover Febuxostat.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Gralise ER 600 milligram extended release 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 Gralise ER has been prescribed for the treatment of idiopathic peripheral neuropathy. 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 Tizanidine Hydrochloride 2 milligram tablets prescribed to treat severe muscle spasms due to a stroke. 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.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 the appeal and determined that the plan is not required to cover Tizanidine Hydrochloride 2 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Stelara solution 45 milligram/0.5 milliliter prefilled syringe prescribed for 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 records submitted at the reconsideration level. The documentation shows Stelara was prescribed to treat plaque psoriasis. The plan has prior authorization requirements for this drug that must be met before they will cover the Stelara. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to Stelara. 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

The enrollee requested Xarelto 15 milligram tablet 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 enrollee purchased Xarelto from a hospital discharge pharmacy for an amount that is less than or equal to the required copayment amount. The plans Evidence of Coverage indicates reimbursement is calculated based on the total cost of the drug, minus the required copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charged. The plan provided information showing the enrollee was in the initial coverage stage of their Part D plan. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the copay. We determined the copay for Xarelto was calculated correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prolia Solution 60 milligram/milliliter pre-filled syringe prescribed in an enrollee with prostate cancer on androgen deprivation therapy with a diagnosis of osteopenia. 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 prescriber indicates Prolia is required due to the enrollee is on androgen deprivation therapy with Leuprolide injections for prostate cancer and the enrollee is on Xtandi which has an increased risk for falls and fractures. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The plan indicates the drug may be considered medically necessary when the enrollee has a medication history use of a bisphosphonate or intolerance to a bisphosphonate. The prior authorization requirements have not been met. A physician reviewed your appeal and determined that the plan is not required to cover Prolia.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hydrocortisone Acetate Suppository 25 milligram prescribed for rectal pain due to an anal fissure. 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 prescriber requests Hydrocortisone Acetate Suppository 25 milligram to treat symptoms due to an anal fissure. However, Medicare does not cover Drug Efficacy Study Implementation drugs. These drugs are not considered Part D eligible drugs.A physician reviewed your appeal and determined that the plan is not required to cover Hydrocortisone Acetate Suppository.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xarelto 20 milligram 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. Xarelto 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 Otezla 30-milligram tablet to treat moderate to severe plaque psoriasis. 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 documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan, with supporting medical documentation, would likely cause harm or not be as effective as the requested 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

You requested Zolpidem 10 milligram tablets prescribed 30 tablets per 30 days for an unknown diagnosis. The plan denied the request because the quantity limit had been exceeded for the calendar. 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 asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this amount of the medication. We did not receive the documentation requested. Without a diagnosis it cannot be established that Zolpidem Tartrate is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. Zolpidem Tartrate is not eligible for coverage under Medicare Part D. Therefore, an exception to the plans quantity limit will not be considered. A physician reviewed your appeal and determined that the plan is not required to cover Zolpidem Tartrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Trulicity 1.5 milligram per 0.5 milliliter subcutaneous injection pen prescribed for the treatment of 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 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. Trulicity 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 cover the requested drug at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nucala 100-milligram Solution Prefilled Syringe to treat severe persistent asthma. 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 formulary alternatives required by the plan would likely not be as effective as the requested drug for this condition, and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not medically necessary. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pregabalin 25 milligram capsule prescribed for spinal stenosis. 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 asked your 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. The documentation shows Pregabalin was prescribed to treat spinal stenosis. 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 Pregabalin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Olanzapine 10 milligram tablet prescribed 60 tablets per 30 days for personality disorder. The Part D plan denied the request for coverage of the drug and also denied a requested quantity of 60 tablets per 30 days which is more than allowed 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 prescriber indicates they prescribed Olanzapine 10 milligram tablet with a quantity of 60 tablets per 30 days to treat personality disorder. The prescriber indicates the enrollee is stable on the current dosage and requires 1 tablet twice a day. 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 Olanzapine 10 milligram tablets with a quantity of 60 tablets per 30 days.
Appeal type: Prescription Drug
Decision: Favorable

The enrollee requested Boostrix TDAP vaccine syringe prescribed for vaccination. The Part D plan denied the request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. We determined that the plan is required to provide reimbursement for their share of the cost with consideration to the cost sharing stage of the enrollee.The record shows the enrollee was given the Boostrix TDAP vaccine in the physicians office. According to the plan's Evidence of Coverage, if an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The documentation submitted includes a receipt showing the enrollee paid for the Boostrix TDAP vaccine and administration fee at full cost. The plan indicated the National Drug Code was missing from the reimbursement request. However, the physicians billing statement includes a valid National Drug Code, 58160-842-43, for the Boostrix TDAP vaccine. Therefore, the reimbursement criteria have been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tadalafil 5 milligram tablet prescribed for benign prostatic hyperplasia. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. Your prescriber indicates that they prescribed Tadalafil to treat benign prostatic hyperplasia and that the enrollee had tried and failed Tamsulosin. However, there was no documentation that the enrollee had also tried one 5-alpha-reductase inhibitor. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation was not provided to show the enrollee has satisfied the plan's coverage criteria.  A physician reviewed your appeal and determined that the plan is not required to cover Tadalafil. 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

The enrollee requested Amlodopine Besylate 40 milligram tablets prescribed daily 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 plan submitted documentation that shows the enrollee was in the initial coverage stage of the Part D benefit when this drug was purchased. According to the plans Evidence of Coverage, Amlodopine Besylate is a tier 1 drug with a copay of $9, in the initial coverage stage. The record shows the full price of the drug was less than the $9 copay amount. Therefore, the charge was based on the total cost of the drug. We determined this drug was paid correctly and no further reimbursement is required by the plan.