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

You requested Cefazolin Sodium 10 gram injection/Sodium Chloride IV solution 0.9%/Cefazolin Sodium 1 gram injection/ and water for IV injection as a compounded drug prescribed for infection. 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 plan submitted documentation that shows you were in the deductible stage for date of service January 19, 2021. You were in the deductible stage for part of the cost and entered the initial stage for the remaining amount for date of service January 26, 2021. For dates of service February 1, 2021, February 8, 2021, February 16, 2021 and February 22, 2021 you were in the initial stage of your plan benefit. You are responsible for the full cost of covered drugs until the deductible amount is satisfied. After the deductible was met, the plan calculated reimbursement based on the total cost of the drug, minus your required copayment amount, and minus the difference between what the plan normally pays for the drug and what the network pharmacy charged you. We determined the Cefazolin Sodium/Sodium Chloride IV solution/Cefazolin Sodium was paid correctly and no further reimbursement is required by the plan. The water for IV injection is excluded from coverage under Part D and not eligible for payment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Acyclovir 5% cream prescribed for herpes viral infection of genitalia and urogenital tract. 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 Acyclovir 5% cream to treat your condition. 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 Acyclovir 5% cream.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tetanus-Diptheria Toxiod 0.4 milligram prescribed for treatment of a wound.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 record shows you received the Tetanus-Diptheria Toxoid while in the emergency center. Medicare Part B covers the Tetanus-Diptheria Toxoid when it is administered for the treatment of a wound. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover Tetanus-Diptheria Toxoid. Please submit your 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% ointment for back, knee and ankle pain. 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. Your doctor stated Lidocaine was prescribed for back, knee and ankle pain. At reconsideration, a diagnosis of spinal stenosis was added, with pain from back surgery 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 Lidocaine 5% ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tacrolimus 1 milligram capsule prescribed daily for kidney transplant status. 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 determined that the plan is not required to cover the Tacrolimus. Medicare records indicate the enrollee received a kidney transplant on April 18, 2021, which was covered by Medicare Part A. Therefore, the transplant is considered a Medicare covered transplant and Tacrolimus is eligible under Medicare Part B. Medicare rules state that a drug covered under Part B cannot be covered under Part D. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tetanus-Dipth-Acell Pertussis 5-2 5 18.5 LF-MCG/0.5 suspension vaccination administration fee.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 record shows you received the Tetanus-Dipth-Acell Pertussis vaccination while in the hospital. Medicare Part B covers the Tetanus-Dipth-Acell Pertussis vaccination when the vaccine is administered due to the treatment of a wound. Medicare rules state that a drug covered under Part B cannot be covered under Part D. Therefore, the Part D plan is not required to cover or provide reimbursement for Tetanus-Dipth-Acell Pertussis administration fee.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Remicade 100 milligram solution reconstituted prescribed for rheumatoid arthritis. 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 Remicade.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diclofenac Epolamine 1.3% transdermal patch prescribed to treat acute pain due to minor strain of the lower back. 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 reconsideration appeal letter shows the enrollees diagnosis of acute pain due to strain of the lower back. This diagnosis is a medically-accepted indication per the Medicare approved compendia. However, there are no medical records to support the diagnosis.Diclofenac Epolamine 1.3% transdermal patch 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, 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 Diclofenac Epolamine 1.3% transdermal patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Prolia 60 milligram/milliliter syringe prescribed for osteoporosis. 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 provided shows Prolia was supplied by you and administered to the enrollee in your office. According to Medicare rules, Part B pays for services and supplies from physician and/or office stock supply, and should be billed as part of a physician service. Therefore, coverage is excluded for any drug for which payment would be available under Parts A or B. We determined the Part D plan is not required to cover Prolia. Please submit your 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Jardiance 10 milligram tablets prescribed for type II diabetes mellitus. 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. Jardiance is a brand drug on Tier 3 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.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 Novolog 100-milligrams/milliliter. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. 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 also researched Medicare systems and reviewed the enrollment data available.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 Avastin 25 microgram/milliliter vial prescribed for malignant neoplasm of rectum. 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 record shows Avastin is being administered to the enrollee in the physician's office. Medicare Part B pays for services and supplies incident to the service of a physician (or other practitioner). Medicare law specifically excludes coverage for any drug for which payment would be available under Medicare Parts A or B for that individual. We determined that the drug is eligible under Medicare Part B. Therefore, the Part D plan is not required to cover Avastin. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dulera HFA 200 microgram/5 microgram inhaler prescribed for asthma. 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.Dulera HFA is a brand drug on Tier 2 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 your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ingrezza 40 milligram capsule prescribed for idiopathic orofacial dystonia. 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 medical records show Ingrezza was prescribed for idiopathic orofacial dystonia not associated with tardive dyskinesia. 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 Ingrezza.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Alprazolam 1 milligram tablets prescribed for trochanteric bursitis, arthralgia of left ankle, hip arthritis. 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 Alprazolam to treat your trochanteric bursitis, arthralgia of left ankle, hip arthritis. 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 Alprazolam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq ER 50 milligram tablets prescribed for urge incontinence. 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.Myrbetriq ER is a brand drug on Tier 3 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.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 Adcirca 40 milligram oral tablet prescribed daily for pulmonary hypertension. 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 the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. We received the documentation and included it in our 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. The prescriber submitted a supporting statement explaining why the alternative formulary drugs would not work for you. However, the medical records do not support why the preferred drug Diltiazem Hydrochloride on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Adcirca
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Thalomid 50 milligram capsule prescribed for angiodysplasia stomach and duodenum with bleeding. 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 Thalomid to treat your condition. 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 Thalomid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fasenra Pen 30 milligram per milliliter Auto-injector prescribed every month for three months then every other month for chronic asthma. 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 Fasenra Pen due to the enrollees chronic asthma. 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 your appeal and determined that the plan is not required to cover Fasenra Pen. 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 Orencia Clickject 125 milligram/milliliter prescribed for rheumatoid arthritis. 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.We requested additional information from your prescriber but did not receive a response. 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 Orencia Clickject. 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 Tetrabenazine 12.5 milligram tablet prescribed daily for 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 records submitted at the reconsideration level. Your medical records show your doctor prescribed Tetrabenazine to treat your tardive dyskinesia. 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 Tetrabenazine. There is no evidence that you have tried deutetrabenazine or valbenazine. 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 Dupixent 300 milligram per 2 milliliter syringe prescribed for chronic rhinitis with nasal septal perforation. 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 Dupixent to treat your chronic rhinitis with nasal septal perforation. However, the Medicare approved compendia do not support the use of this drug for your condition. 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 Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for a tiering exception for Ozempic 2 milligram per 1.5 milliliter subcutaneous injection pen.  The 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. Ozempic is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the same condition on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to cover the Ozempic at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Adderall 10 milligram tablets prescribed to treat depression and anxiety. 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 Allerall 10 milligram tablets to treat depression and anxiety. 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 Allerall 10 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lupron Depot-Ped 7.5 milligram kit for intramuscular injection prescribed as directed for prostate cancer. 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 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 this medication. We did not receive the documentation requested.The coverage determination request states the physician prescribed Lupron Depot-Ped to treat metastatic prostate cancer. However, medical records were not submitted for review to support the enrollees diagnosis. 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 Lupron Depot-Ped.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Capecitabine 500 milligram tablet prescribed for advanced pancreatic cancer. 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 Capecitabine is recommended to be used with concurrent radiation after neoadjuvant therapy for resectable pancreatic cancer. However, this drug may be eligible for coverage under Medicare Part B. We determined that the plan is not required to cover Capecitabine 500 milligram tablet.