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

At issue is Repatha 420 milligrams per 3.5 milliliters Pushtronex system solution cartridge prescribed to treat the enrollee with hyperlipidemia. 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.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 Repatha 420 milligrams per 3.5 milliliters Pushtronex system solution cartridge.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sodium Phenylbutyrate 500 milligram tablet prescribed for amytrophic lateral 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 Sodium Phenylbutyrate prescribed for amytrophic lateral 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 Sodium Phenylbutyrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Soliqua 100-33 units-microgram/milliliter subcutaneous solution prescribed as directed for type II diabetes mellitus without complications. 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 Soliqua.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Linzess 290 microgram capsules prescribed for chronic idiopathic constipation. 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.Linzess is a brand drug on Tier 4 of the plans formulary. There are no other 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 Orphenadrine Citrate 100 milligram tablets prescribed for chronic pain syndrome. 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 requested additional information from the prescriber. Specifically, we requested medical records and a prescriber statement to support all formulary alternatives were tried and failed. The prescriber submitted medical records and a statement, which we included in this review.The submitted documentation indicates the prescriber ordered the drug at issue for the enrollees noted condition. 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 Stelara 45-milligrams/0.5-milliliter Syringe to treat hidradenitis suppurativa. 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 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 Creon 120000-unit/24000-unit/76000-unit delayed release capsules prescribed for pancreatic insufficiency. 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.Creon is a biologic on Tier 3 of the plans formulary. There are no other biologics of the same type on the lower cost sharing tiers. Therefore, this biologic 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 Repatha Sureclick 140 milligram/milliliter solution auto injector prescribed as directed for severe atherosclerosis heart disease. 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 Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Alosetron 1 milligram tablet prescribed twice daily for irritable bowel syndrome with diarrhea. 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 Alosetron to treat the male enrollees irritable bowel syndrome with diarrhea. However, the Medicare approved compendia do not support the use of this drug for this diagnosis in men.A physician reviewed the appeal and determined that the plan is not required to cover Alosetron.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Taltz 80-milligram/milliliter auto-injector prescribed for 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 submitted documentation did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed the appeal and determined that the plan is not required to cover Taltz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a formulary exception request for Nourianz 40 milligram tablets prescribed to treat the enrollee with Parkinsons disease. 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.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 Nourianz 40 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ozempic 2 milligrams per 1.5 milliliter solution, 0.5 milligram prescribed weekly for type 2 diabetes mellitus. 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 1 of the plans formulary. There are no cost-sharing tiers lower than Tier 1; 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 Arikayce 590 milligrams per 8.4 milliliter oral inhalation suspension prescribed daily for pulmonary infection and bronchiectasis. 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 Arikayce to treat the enrollees pulmonary infection and bronchiectasis. However, the Medicare approved compendia do not support the use of this drug for these diagnoses. The mycobacterium culture was negative.A physician reviewed the appeal and determined that the plan is not required to cover Arikayce.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lorazepam 0.5 milligram tablet prescribed to take 1-2 tablets every 6 hours while awake as needed for anxiety disorder, unspecified. 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. Lorazepam 0.5 milligram tablet is prescribed for anxiety disorder, unspecified. We requested additional information from the prescriber but did not receive a reply. The documentation was insufficient and it was unable to confirm the quantity requested and the medical necessity of any additional quantities that may be requested that are over the plans quantity limit of 150 tablets per 30 days.   A physician reviewed your appeal and determined that the plan is not required to cover Lorazepam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is reimbursement for the Shingrix vaccine prescribed for shingles prophylaxis. The Part D plan denied the request.We requested the case to perform an independent and de novo review. To make our decision, we reviewed 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 submitted documentation shows proof of payment for the vaccine, and administration fee. Medicare rules state that drug claims must include a valid National Drug Code that is listed with the Food and Drug Administration and a valid National Provider Identifier (NPI) number for the prescriber. The record does not include a National Drug Code for the Shingrix vaccine or the prescribers NPI. Therefore, we determined that the plan is not required to reimburse the enrollee for the Shingrix vaccine and administration fee at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% ointment prescribed to treat the diagnoses of chronic pain syndrome and bilateral knee osteoarthritis. 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.We asked the prescriber to send us information regarding the enrollees condition. Specifically, we asked the prescriber to submit a prescribers statement, clarification of the enrollees diagnosis, and additional documentation to show why the enrollee needs this medication.The doctor prescribed Lidocaine 5% ointment to treat the diagnoses of chronic pain syndrome and bilateral knee osteoarthritis. Upon redetermination, the Part D plan denied the request stating that the plans prior authorization requirements were not satisfied. However, the medical records provided fail to support that the enrollee has met the criteria for a medically acceptable indication per the approved Medicare compendia.A physician reviewed the appeal and determined that the plan is not required to cover Lidocaine 5% ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexlizet 180-10-milligram tablet to treat 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 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 Lidocaine 5% patch prescribed daily for pain in left and right foot and tendonitis of left posterior tibial tendon. 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 diagnoses. We also asked for medical records or other documentation to show why this medication was needed. We received the documentation and included it in our review.The documentation shows the prescriber ordered Lidocaine 5% patch to treat the enrollees pain in left and right foot and tendonitis of left posterior tibial tendon. However, the Medicare approved compendia do not support the use of this drug for these diagnoses. The prescriber states the enrollee has diabetic neuropathy but the medical records do not support this diagnosis.A physician reviewed the appeal and determined that the plan is not required to cover Lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nucynta 50-milligram tablet to treat chronic low back pain with bilateral lumbar radiculopathy. The Part D plan denied the request. The requested drug is not on the plans formulary. We received the case to perform an independent and de novo review. To make our decision, we reviewed the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you.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 Synthroid 75 microgram tablets to treat the enrollees condition. 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.Synthroid 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 Shingrix prescribed for shingles vaccination. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 submitted documentation shows the enrollee was administered the requested drug at the prescriber's office. The plans Evidence of Coverage states, if the enrollee pays the full cost of a prescription, then they may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that was paid for the drug was not provided. Therefore, we determined that the plan is not required to provide reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexletol 180 milligram tablets prescribed for dyslipidemia. 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 Nexletol to treat the enrollees condition of dyslipidemia. 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 Nexletol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Potassium Citrate-Citric Acid 1100-milligram/5-milliliter-334-milligram/5-milliliter oral solution. 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 drug at issue is not Food and Drug Administration approved. 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 Xeljanz 5 milligram tablet prescribed twice daily for MDA 5 positive dermatomyositis. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available.The documentation shows Xeljanz was prescribed to treat MDA 5 positive dermatomyositis. However, the Medicare approved compendia do not support the use of this drug for the enrollee's condition. A physician reviewed your appeal and determined that the plan is not required to cover Xeljanz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Humira 40 milligram/0.8 milliliter prefill syringe kit prescribed as directed for pyoderma gangrenosum. 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 Humira to treat your pyoderma gangrenosum. 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 Humira.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ibrance 125 milligram capsule prescribed for unknown diagnosis.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level.The plan submitted documentation showing the enrollee was in the catastrophic coverage stage when the requested drug was purchased on March 1, 2021. The plans 2021 Evidence of Coverage states that during this stage, the cost of a covered drug will be either coinsurance of 5 percent or a copayment, whichever is the larger amount. In this case, the enrollee's cost share was based on the larger amount of 5 percent coinsurance. We determined that the plan calculated the coinsurance correctly and no further reimbursement is required.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ibrance 125 milligram capsule prescribed for unknown diagnosis.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level.The plan submitted documentation showing the enrollee was in the catastrophic coverage stage when the requested drug was purchased on March 30, 2021. The plans 2021 Evidence of Coverage states that during this stage, the cost of a covered drug will be either coinsurance of 5 percent or a copayment, whichever is the larger amount. In this case, the enrollee's cost share was based on the larger amount of 5 percent coinsurance. We determined that the plan calculated the coinsurance correctly and no further reimbursement is required.