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

The enrollee requested Hydralazine Hydrochloride prescribed for an 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 record shows the plan reprocessed a claim for the Hydralazine Hydrochloride and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, you are responsible for your share of the copay. We have determined that the plan is correct in its calculation of additional copay amounts due to reconciliation of your true out of pocket accumulation.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Tradjenta 5 milligram tablet prescribed for an 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 record shows the plan reprocessed a claim for the Tradjenta and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, you are responsible for your share of the copay. We have determined that the plan is correct in its calculation of additional copay amounts due to reconciliation of your true out of pocket accumulation.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Forteo solution pen-injector 620 microgram/2.48 milliliters prescribed for moderate osteopenia. 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 Forteo was prescribed to treat moderate osteopenia. 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 Forteo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Sildenafil 20 milligram tablets prescribed for pulmonary hypertension, unspecified. The Part D plan denied coverage.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 records submitted at the reconsideration level. We requested additional documentation from the prescribing physician. Specifically, we requested medical records and a prescriber statement to support the enrollee met the plans prior authorization coverage criteria. However, we did not receive additional documentation.The submitted documentation indicates the prescriber ordered Sildenafil for unspecified pulmonary hypertension. 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 requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cayston 75 milligram inhalation solution prescribed for pseudomonas aeruginosa infection without cystic fibrosis. 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 Cayston inhalation solution was prescribed to treat pseudomonas aeruginosa infection without cystic fibrosis. 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 Cayston inhalation solution.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Azathioprine 50 milligram tablet prescribed daily to prevent rejection of a 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 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 Azathioprine. Medicare records indicate the enrollee received a kidney transplant on March 5, 2005, which was covered by Medicare Part A. Therefore, the transplant is considered a Medicare covered transplant and Azathioprine is eligible under Medicare Part B. Medicare rules state that a drug covered under Part B cannot be covered under Part D. 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 Famotidine 40 milligrams per 5 milliliters suspension prescribed to treat dysphagia. 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 documentation shows the doctor prescribed Famotidine 40 milligrams per 5 milliliters suspension to treat dysphagia. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed the appeal and determined that the plan is not required to cover Famotidine 40 milligrams per 5 milliliters suspension.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide-Formoterol Fumarate 160/4.5-microgram/Activation HFA to treat pulmonary fibrosis with chronic 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.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 Cyclobenzaprine Hydrochloride 10 milligram tablets prescribed for muscle spasms due to spinal degenerative joint disease. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation indicates the prescriber ordered Cyclobenzaprine Hydrochloride for muscle spasms due to spinal degenerative joint disease. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xifaxan 550 milligram tablet prescribed twice daily for hepatic encephalopathy. 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 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 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 Privigen 10% vial prescribed 1000 milliliter per 28 days for idiopathic autonomic peripheral neuropathy, elevated antibody titer and auto-immune gastrointestinal dysmotility. 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 Privigen to treat idiopathic autonomic peripheral neuropathy, elevated antibody titer and auto-immune gastrointestinal dysmotility. However, the Medicare approved compendia do not support the use of this drug for the enrollees conditions. A physician reviewed your appeal and determined that the plan is not required to cover Privigen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cosentyx Sensoready 150 milligram per milliliter dose pen prescribed 300 milligrams weekly for five weeks, then every four weeks for psoriasis vulgaris. 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. 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 Cosentyx Sensoready 150 milligram per milliliter dose pen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Zolpidem Tartrate 5 milligram tablets prescribed for insomnia. The Part D plan denied coverage.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 records submitted at the reconsideration level. We requested additional documentation from the prescribing physician. Specifically, we requested medical records to support the enrollee has tried and failed the alternative medication Doxepin. However, we did not receive additional documentation.The documentation on hand includes a physician supporting statement. The supporting statement does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.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 formulary exception request for Gemtesa 75 milligram tablets prescribed for frequency of micturition. 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.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 the Gemtesa at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine Hydrochloride 5-milligram tablet for long term treatment of muscle spasms and pain. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.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 tiering exception request for Ozempic 0.05 Pen Injector to treat Type 2 diabetes mellitus with hyperglycemia. 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.This drug is being 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.Our physician reviewer's opinion is that non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Edex 20 microgram cartridge prescribed for erectile dysfunction. 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 Edex because it was prescribed to treat 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

At issue is Calcipotriene 0.0005% Cream to treat transient acantholytic dermatosis. 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 Viberzi 100-milligram tablet to treat fecal urgency and diarrhea, unspecified. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows you were prescribed Viberzi for fecal urgency and diarrhea, unspecified. We asked the prescriber to send us documentation of diagnosis, prior authorization, and medical records. The prescriber submitted documentation.The records submitted do not contain documentation verifying the diagnosis of irritable bowel syndrome with diarrhea. As such, 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

You requested Armodafinil 250 milligram tablet for relapsing remitting multiple sclerosis and chronic fatigue secondary to 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. The documentation shows Armodafinil was prescribed to treat relapsing remitting multiple sclerosis and chronic fatigue secondary to multiple sclerosis. 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 Armodafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Sodium Chloride 3% vial-neb 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.According to Medicare rules, drugs that are not approved by the Food and Drug Administration are excluded from coverage under Part D. Sodium Chloride 3% vial-neb has not been approved by the Food and Drug Administration to be safe and effective. Therefore, we determined that the plan is not required to cover the Sodium Chloride 3% vial-neb. If you purchased drugs/products that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug/product. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ventolin Hydrofluoroalkane (HFA) 108 (90 base) micrograms per actuation aerosol solution. The Part D plan denied the appeal request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.Ventolin HFA 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 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 a formulary exception request for Crestor 5 milligram tablets prescribed for mixed hyperlipidemia. 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.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 submitted documentation does 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 the Crestor at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Dronabinol 2.5 milligram capsule prescribed for infantile spinal muscular atrophy. 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 was prescribed Dronabinol to promote weight gain due to a diagnosis of infantile spinal muscular atrophy. The Food and Drug Administration and Medicare approved compendia do not support the use of Dronabinol for the provided diagnosis. Therefore, the requested drug is not eligible for coverage under Medicare Part D. We determined that the plan is not required to provide coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Vaqta injection prescribed for vaccination. The Part D plan denied the enrollees 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 coverage was allowed for the Vaqta vaccination. The plan calculated reimbursement to the enrollee based on the approved cost of the drug, plus dispensing fee, and administration fee, and minus the enrollees required co-payment amount. According to the plan, the provider charged you more than the approved cost of the drug. Therefore, we determined that the plan is not required to provide additional reimbursement for the Vaqta vaccine. The plan provided coverage and reimbursement in accordance with your plans out-of-network(physicians office) rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Spiriva Handihaler 18 microgram inhalant prescribed for the enrollees condition. The Part D plan denied the request for a tiering exception and additional reimbursement.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.Spiriva Handihaler 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 the appeal and determined that the plan is not required to grant the request for a tiering exception and additional reimbursement.