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

At issue is Crysvita 30 milligram/milliliter vial prescribed unknown frequency for X-linked hypophosphatemia. 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. The medical records show the doctor prescribed Crysvita to treat the enrollees X-linked hypophosphatemia. 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 Crysvita. There is no evidence that there was a reduction in the ratio of the maximum rate of tubular phosphate reabsorption to the glomerular filtration rate. 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 Januvia 100 milligram tablet prescribed daily. 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.Januvia 100 milligram tablet 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 your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Skyrizi 150-milligram Dose Kit 2-Syringes to treat 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/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 Humira 40 milligram per 0.4 milliliter pen-injector. 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.Humira pen-injector is a biological product drug on Tier 4 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: Unfavorable

At issue is Synthroid 100 microgram tablet prescribed for hypothyroidism. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The prescriber indicates they prescribed Synthroid 100 microgram tablets to treat hypothyroidism. However, Synthroid 100 microgram tablets are not on the plans formulary. 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 Synthroid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Shingrix Vial Kit for shingles prophylaxis. 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.DRUG is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methylphenidate HCL tablet 5 milligram prescribed for chronic fatigue syndrome related to opioid use. 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 that Methylphenidate HCL was prescribed to treat chronic fatigue syndrome related to opioid use. 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 Methylphenidate HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 2.5%/Prilocaine 2.5% Cream 90-grams/30-days to treat multiple joint 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 plan limits the amount of Lidocaine 2.5%/Prilocaine 2.5% Cream to 30-grams/30-days. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the condition or would be likely to cause harm. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that quantity limit criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fluocinolone oil 0.01% ear drop prescribed for chronic eczematoid otitis externa. 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. A physician reviewed your appeal and determined that the plan is not required to cover Fluocinolone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering request for Clomiphene Citrate 50 milligram tablet prescribed as directed for unknown diagnosis. The Part D plan denied the request. We received the case to perform an independent and de novo review. We reviewed all documentation submitted. The documentation shows a tiering request for Clomiphene Citrate to treat an unknown diagnosis. 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 Euflexxa Prefilled Solution Syringe 20 milligram/2 milliliter prescribed for osteoarthritis of the knee. The Part D plan denied the request stating the item is considered to be a medical device and may be available under Medicare Part B.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 they prescribed Euflexxa Prefilled Solution Syringe 20 milligram/2 milliliter to treat osteoarthritis of the knee. This is a drug that is given intra-articular by a healthcare provider. Therefore, the drug is not eligible for coverage under Part D benefits but may be eligible for coverage under Medicare Part B benefits. A physician reviewed your appeal and determined that the plan is not required to cover Euflexxa Prefilled Solution Syringe 20 milligram/2 milliliter.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Vraylar 1.5-milligram capsule to treat delusional disorder and paranoid personality disorder. 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.Vraylar is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same condition. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Megestrol Acetate 40 milligram tablet prescribed daily for cachexia and anorexia. 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 documentation shows the doctor prescribed Megestrol Acetate to treat the enrollees intertrigo. However, the Medicare approved compendia do not support the use of this drug for these conditions unless they are related to certain diagnoses that were not documented. A physician reviewed the appeal and determined that the plan is not required to cover Megestrol Acetate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Betimol 0.25% Solution to treat glaucoma. 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 Dupixent 300 milligram/2-milliliter syringe prescribed at unknown frequency for atopic dermatitis. 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. The medical records show your doctor prescribed Dupixent to treat the enrollees atopic dermatitis. 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 Dupixent. There is no evidence that the enrollee has tried an immunomodulatory agent. 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 Farxiga 10 milligram tablet, a quantity 30 tablets per 30 days prescribed for the following diagnoses type 2 diabetes mellitus, cardiomyopathy, and chronic heart failure. 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. We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records and other documentation to show why the medication is needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the enrollee. 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, no medical records were provided to support why other drugs on the plans formulary would not work for the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Farxiga.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine Hydrochloride 10-milligram tablet to treat psoriatic arthritis. 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 Tacorlimus 0.1% ointment prescribed twice daily for intertrigo. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows the doctor prescribed Tacorlimus 0.1% ointment to treat the enrollees intertrigo. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed the appeal and determined that the plan is not required to cover Tacorlimus 0.1% ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Omeprazole 20 milligram delayed release capsules, 120 capsules per 30 days, prescribed for gastroesophageal reflux disease with esophagitis and peptic ulcer. 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. The amount of medication requested, 120 capsules per 30 days, exceeds the plans quantity limit for this drug, which is 1 capsule per day, or 30 capsules per 30 days. During this review, a request was submitted to the prescriber to address the need to exceed the amount of medication allowed by the plan and to provide supporting medical records. A reply from the prescriber was not received. An exception to the quantity limit criteria is not supported by the submitted documentation. A physician reviewed the appeal and determined that the plan is not required to cover 120 capsules per 30 days of delayed-release Omeprazole.
Appeal type: Prescription Drug
Decision: Favorable

You requested Myrbetriq 25 milligram 24 hour extended-release oral tablet prescribed daily for interstitial cystitis (chronic) without hematuria. 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 Myrbetriq was prescribed to treat interstitial cystitis (chronic) without hematuria. Medical records indicate the enrollee has overactive bladder in association with interstitial cystisis. The Medicare approved compendia support the use of this drug for the noted condition. A physician reviewed your appeal and determined that the plan is required to cover Myrbetriq.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Drysol Dabomatic 20% prescribed for hyperhidrosis. The Part D plan denied your request stating the drug is off formulary.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. Drysol Dabomatic is not a Part D eligible drug. Medicare Part D drugs are drugs that require Food and Drug Administration approval.  A physician reviewed your appeal and determined that the plan is not required to cover Drysol Dabomatic.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Calcium Glucosomina chewable pills prescribed for unknown diagnosis. 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 record shows the enrollee purchased drugs from a pharmacy outside of the United States. We determined that the plan is not required to cover or reimburse the enrollee for Calcium Glucosomina because it was purchased in Mexico. Drugs purchased outside of the United States are excluded from coverage. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Clindzmycin prescribed for unknown diagnosis. 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 record shows the enrollee purchased drugs from a pharmacy outside of the United States. We determined that the plan is not required to cover or reimburse the enrollee for Clindzmycin because it was purchased in Mexico. Drugs purchased outside of the United States are excluded from coverage. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Clonazepan drops prescribed for unknown diagnosis. 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 record shows the enrollee purchased drugs from a pharmacy outside of the United States. We determined that the plan is not required to cover or reimburse the enrollee for Clonazepan because it was purchased in Mexico. Drugs purchased outside of the United States are excluded from coverage. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Dexabion prescribed for unknown diagnosis. 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 record shows the enrollee purchased drugs from a pharmacy outside of the United States. We determined that the plan is not required to cover or reimburse the enrollee for Dexabion because it was purchased in Mexico. Drugs purchased outside of the United States are excluded from coverage. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Ketrolac 10 milligram tablet prescribed for unknown diagnosis. 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 record shows the enrollee purchased drugs from a pharmacy outside of the United States. We determined that the plan is not required to cover or reimburse the enrollee for Ketrolac because it was purchased in Mexico. Drugs purchased outside of the United States are excluded from coverage. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Naprocone 550 milligram tablet prescribed for unknown diagnosis. 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 record shows the enrollee purchased drugs from a pharmacy outside of the United States. We determined that the plan is not required to cover or reimburse the enrollee for Naprocone because it was purchased in Mexico. Drugs purchased outside of the United States are excluded from coverage. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.