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

At issue is a request for coverage of Pregabalin 75 milligram capsule prescribed for cervical disc disorder with myelopathy, lumbar disc disorder with myelopathy and lumbar radiculitis. 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 received documentation that shows Pregabalin was prescribed to treat cervical disc disorder with myelopathy, lumbar disc disorder with myelopathy and lumbar radiculitis. However, the Medicare approved compendia do not support the use of this drug for your conditions. 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 Ziprasidone Hydrochloride 20 milligram capsules prescribed to treat an enrollee with major depressive disorder and post-traumatic stress disorder. The Part D plan denied the appeal 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 Ziprasidone Hydrochloride 20 milligram capsules to treat major depressive disorder and post-traumatic stress disorder. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted conditions.A physician reviewed the appeal and determined that the plan is not required to cover Ziprasidone Hydrochloride 20 milligram capsules.
Appeal type: Prescription Drug
Decision: Unfavorable

You asked for reimbursement for a Shingrix Vial Kit. 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 information provided does not include a receipt showing the amount requested of $320.00 was paid for this drug. There is no supporting documentation showing the amount was actually paid.We determined that the plan is not required to cover Shingrix Vial Kit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ajovy 225milligram/1.5 milliliter prefilled syringe prescribed as directed for migraine prophylaxis. 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 Ajovy.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ondansetron Hydrochloride prescribed for severe recurring 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. The prescriber indicated that Ondansetron Hydrochloride is prescribed to treat severe recurring nausea and vomiting. However, the Medicare approved compendia do not support the use of this drug for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Ondansetron Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xifaxan 550 milligram tablets prescribed as directed for constipation, unspecified and abdominal distention. 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 Xifaxan to treat your constipation, unspecified and abdominal distention. 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 Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trikafta 100-50-75 milligrams day (D)/150 milligram night (N) tablets. 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.Trikafta 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 Repatha 140 milligram/milliliter solution prefilled syringe prescribed as directed for hyperlipidemia, unspecified. 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 Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nexletol 180 milligram tablet prescribed as directed for hyperlipidemia, unspecified. 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 Nexletol to treat your hyperlipidemia. However, the records submitted do not show heterozygous familial hypercholesterolemia or established atherosclerotic cardiovascular disease. 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 Nexletol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Soliris 300 milligrams per 30 milliliters vial to treat myasthenia gravis. 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 additional information regarding the enrollees condition. We asked for medical records or other documentation (e.g., physician orders) supporting the reconsideration request. We did not receive the requested documentation.Upon reconsideration, the prescribers statement form indicates that Soliris will be given by gravity and not on a pump. However, the Soliris referral form signed and dated by the prescriber on February 12, 2021, shows that there are no boxes checked off indicating the administration method for the requested drug. The pharmacy work order of June 10, 2021, indicates Soliris was prescribed to be given intravenously, every 14 days, at 400 milliliters per hour via a Curlin infusion pump. There are no physician orders indicating Soliris is to be administered via gravity. Home health visit notes dated June 1, 8, and 21, 2021; show skilled nursing services were provided to access an intravenous site and to administer Soliris via a Curlin infusion pump. The clinical documentation supports that Soliris is to be administered at home via a Curlin pump. Therefore, we have determined that the drug is not eligible for Part D coverage, but would be covered under Medicare Part B. Additionally, Soliris is not included on the plans formulary (list of covered drugs). The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vascepa 1 gram capsules. 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.Vascepa 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. 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 Dextroamphetamine-Amphetamine Extended Release 24 hour 20 milligram capsule prescribed to take 2 capsules a day with a quantity requested of 60 tablets per 30 days for attention deficit hyperactivity disorder. 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 submitted additional information and indicates that Dextroamphetamine-Amphetamine Extended Release 24 hour 20 milligram capsule is prescribed 2 capsules a day for attention deficit hyperactivity disorder. The documentation submitted from the prescriber does not support the current need for a quantity more than the plan allows or for a quantity more than the recommended dosage for a Dextroamphetamine-Amphetamine extended release capsule per Medicare approved compendia. The documentation does not support a medical necessity for an exception to the plans quantity limit.  A physician reviewed your appeal and determined that the plan is not required to cover Dextroamphetamine-Amphetamine Extended Release 24 hour 20 milligram capsule with a quantity of 60 capsules per 30 days.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trihexyphenidyl Hydrochloride 2 milligram tablet prescribed for Parkinsons 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 prescriber indicates Trihexyphenidyl Hydrochloride 2 milligram tablet is prescribed for Parkinsons disease. However, the drug is 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 prescriber does not indicate why the other alternatives on the plans formulary would not work.A physician reviewed your appeal and determined that the plan is not required to cover Trihexyphenidyl Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rocklatan 0.02-0.005% solution prescribed for glaucoma. 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 records indicate that the prescriber requests Rocklatan to treat glaucoma. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported. A physician reviewed your appeal and determined that the plan is not required to cover Rocklatan 0.02-0.005% solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate Mofetil 500-milligram tablet to treat idiopathic usual interstitial pneumonia. 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 formulary exception request for Moviprep 4.7 gram/5.9 gram/100 gram/1.015 gram/2.691 gram/7.5 gram kit prescribed for abdominal pain. 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 or other documentation to show why the enrollee needs the medication. 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.The documentation shows the prescriber ordered Moviprep for abdominal pain. 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 Moviprep.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Oxymorphone Hydrochloride 20 milligram extended release tablets prescribed for chronic pain due to lumbar radiculopathy. The case was auto-forwarded by the plan.  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 enrollee needs the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the enrollee. We received the requested information and included it in this 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 for the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Oxymorphone Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sildenafil 20-milligram tablet three times a day to treat an unknown condition. The case was auto-forwarded by the plan.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 asked your prescriber to send us a prescriber statement, answers to prior authorization coverage criteria, and medical records. We received the documentation and included it in our review.At reconsideration, the diagnoses of systemic sclerosis in the setting of mixed connective tissue disease and severe Raynauds disease. The prescriber stated that the enrollee is receiving 20 milligrams three times per day.  However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, 60 milligrams per day as prescribed, for the treatment of these conditions. 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 Gralise 600 milligram tablet prescribed for chronic pain syndrome. 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 Gralise was prescribed for chronic pain syndrome. 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 Gralise.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a direct member reimbursement request for Sucralfate 1 gram tablets. 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 record does not contain a receipt for purchase of the requested drug, an indication as to which pharmacy the requested drug was purchased from, or an indication as to the prescriber of the drug.The QIC has determined that the plan is not required to reimburse the Sucralfate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Symbicort HFA 160-4.5 microgram. 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 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 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.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 Buprenorphine Hydrochloride 8 milligram sublingual tablets prescribed for chronic pain. 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 prescriber ordered Buprenorphine Hydrochloride sublingual tablets for chronic pain. However, the Medicare approved compendia do not support the use of this drug, in sublingual tablet form, for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Buprenorphine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception for Praluent 75 milligram/milliliter pen.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 not on the plans formulary. Per Medicare rules, non-formulary drugs are 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 Rocklatan 0.005%/0.02% ophthalmic solution prescribed for ocular hypertension. 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 or other documentation to show why the enrollee needs the medication. 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. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported.A physician reviewed your appeal and determined that the plan is not required to cover Rocklatan.