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

You requested reimbursement for a 100-day supply of Atorvastatin Calcium 10 milligram 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 records and prescriber materials support payment of the 100-day supply of Atorvastatin Calcium. The record shows the pharmacy was in the service area, and not outside of the United States or its territories. Therefore, the 30-day supply restriction imposed by the plan was not applicable. We determined that the plan is required to reimburse the 100-day supply of Atorvastatin Calcium.
Appeal type: Prescription Drug
Decision: Favorable

You requested reimbursement for a 100-day supply of Tamsulosin Hydrochloride 0.4 milligram capsules 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 records and prescriber materials support payment of the 100-day supply of Tamsulosin Hydrochloride. The record shows the pharmacy was in the service area, and not outside of the United States or its territories. Therefore, the 30-day supply restriction imposed by the plan was not applicable. We determined that the plan is required to reimburse the 100-day supply of Tamsulosin Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Xiidra 5% eye drops prescribed for dry eye 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. 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 for this medication. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. 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 Stelara 90 milligrams per milliliter injection 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 records submitted at the reconsideration level.Your medical records show your doctor prescribed Stelara 90 milligrams per milliliter injection to treat plaque psoriasis. Your 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.The QIC notes that upon reconsideration, the prescriber has revised the drug request to Stelara 45 milligrams per 0.5 milliliters syringe. However, the new drug request must first be appealed to the Part D plan to conduct a redetermination (first level of appeal) before we can review your case.A physician reviewed your appeal and determined that the plan is not required to Stelara 90 milligrams per milliliter injection, as the prior authorization requirements were not satisfied. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Effer-K 10 milliequivalent effervescent tablets prescribed for hypokalemia. The Part D plan denied your 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.The drug at issue is not Food and Drug Administration approved. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. 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

You requested Dextroamphetamine/Amphetamine ER 30 milligram capsules prescribed three time daily for chronic daytime fatigue associated with a diagnosis of multiple sclerosis. 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 Dextroamphetamine/Amphetamine ER to treat your chronic daytime fatigue associated with a diagnosis of multiple sclerosis. 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 Dextroamphetamine/Amphetamine ER.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Budesonide 0.5 milliigram/2 milliliter ampule prescribed for chronic obstructive pulmonary disease. 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 Budesonide was prescribed for chronic obstructive pulmonary disease. However, this drug may be eligible for coverage under Medicare Part B. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals, which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover Budesonide. Please consider submitting this request to Medicare Part B. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.We determined that the plan is not required to cover Budesonide.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gamunex-C 175-milligrams/vial Infusion to treat non-familial hypogammaglobinemia. 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

You requested Calcipotriene 0.005% cream prescribed for actinic keratosis. 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 doctorprescribed Calcipotriene 0.005% cream for actinic keratosis. 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 Calcipotriene.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xhance Exhaler Suspension 93 micrograms per actuation prescribed for bilateral eustachian tube disorder. 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.The doctor prescribed Xhance to treat the enrollees bilateral eustachian tube disorder. 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 Xhance.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ondansetron Hydrochloride 8 milligram oral tablet prescribed for nausea and vomiting. 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 your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.At initial determination the diagnosis of nausea and vomiting was given. At reconsideration the diagnosis of nausea and vomiting with history of stomach cancer was given. However, no medical records were submitted to support these conditions. Therefore, it cannot be determined if the requested drug was prescribed for a medically accepted indication supported by the Medicare approved compendia.A physician reviewed your appeal and determined that the plan is not required to cover Ondansetron Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligram/milliliter solution prescribed twice daily for atherosclerotic heart disease of native coronary artery without angina pectoris. 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 all the 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 Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eszopiclone 3 milligram tablets prescribed to treat 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 records submitted at the reconsideration level.Your medical records show your doctor prescribed Eszopiclone 3 milligram tablets to treat insomnia. Your 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 your appeal and determined that the plan is not required to cover Eszopiclone 3 milligram tablets, as the prior authorization requirements were not satisfied. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dapsone 7.5% Topical Gel with Pump to treat acne rosacea. 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 Lyrica CR 165 milligram extended release tablet prescribed twice daily for diabetic peripheral neuropathy. 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. We asked your prescriber to send us information regarding your condition. We also asked for medical records to show why you need this medication. We received the documentation and included it in our review. Your physician sent an attestation and a questionnaire.Your physician states he ordered Lyrica CR to treat your diabetic peripheral neuropathy. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. There must be documentation that Gabapentin had been tried or was contraindicated. 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 cover Lyrica CR. The medical records do not support Gabapentin has been tried or is contraindicated. 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

You requested Otezla 30 milligram tablets prescribed to treat cicatricial permphigold. 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 cicatricial permphigold. Otezla is not on your plans formulary. 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

You requested Liquacel liquid protein for daily protein requirements. The Part D plan denied your request. We received a reconsideration request.We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We determined that the plan is not required to cover Liquacel liquid protein because it is available over the counter (OTC). OTC products are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. 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: Favorable

At issue is Briviact 75 milligram tablets prescribed four tablets per day to treat partial seizures. The Part D plan denied the request.  We received a reconsideration request.We performed an independent and de novo review. We reviewed all documentation submitted. The plan limits the amount of Briviact to two tablets a day. The prescriber has indicated that the number of doses of the requested drug allowed by the plan has not been effective in treating the condition. Therefore, an exception to the plans quantity limit coverage criteria is medically necessary. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Megestrol Acetate 40 milligram tablets. The Part D plan denied the request for coverage. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The documentation indicates that Megestrol Acetate has been prescribed for appetite stimulation due to the enrollees unexplained weight loss and low body mass index. 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 your appeal and determined that the plan is not required to cover the Megestrol Acetate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Austedo 9 milligram tablets prescribed to take 2 tablets a day to treat tardive dyskinesia. 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 Austedo 9 milligram tablets.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Mayzent 2 milligram oral tablet to treat multiple sclerosis.   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.  In the Reconsideration appeal the prescriber provided an attestation letter that stated that the requested drug was providing clinical benefit to the enrollee.  As well, the prescriber provided an updated laboratory report dated 5/17/2021 that shows a normal absolute lymphocyte count of 1637 cells/microliter.The documentation satisfies the plans coverage criteria.  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 Premarin vaginal cream. 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. We asked your prescriber to send us information regarding your condition. We also asked for medical records and other documentation to show why you need this medication. We did not receive the documentation requested.In this case, no medical records were provided by the prescriber or included in the case review. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Premarin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Restasis 0.05% Opthalmic Droperette prescribed twice daily for keratoconjunctivitis sicca. 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. We also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Restasis to treat your keratoconjunctivitis sicca. Your 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 that you have satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Restasis. 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

You requested Ipratropium-Albuterol 0.5-3 milligram/3 milliliter nebulizer ampules prescribed for pulmonary fibrosis. The Part D plan denied the 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.The drug at issue is for use with a nebulizer in the enrollees home. This is eligible for coverage under Part B. The drug is not eligible for Part D coverage.We determined that the plan is not required to cover Ipratropium-Albuterol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Denta 5000 Plus cream prescribed for implants. 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. You are requesting off-formulary Denta 5000 Plus. We researched Medicare resources and found that the repackaged drug Denta 5000 Plus has a National Drug Code that is not listed with the Food and Drug Administration. Therefore, we determined that the plan is not required to cover the Denta 5000 Plus. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.