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

You requested Lidocaine Ointment 5% prescribed for neuralgia and neuritis, unspecified. 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. Your prescriber indicates they prescribed Lidocaine Ointment 5% to treat neuralgia and neuritis, unspecified. 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 Ointment.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Simbrinza 1%-0.2% ophthalmic drops prescribed for primary open angle glaucoma. 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. Simbrinza is not included in the plans formulary. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. During this review, a request was submitted to the prescriber to address the alternative medications included in the plans formulary and to provide supporting medical records. The prescriber did not respond to the request. Therefore, an exception to the plans 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 a request for coverage of Morphine Sulfate ER 15 milligram extended release tablets prescribed for post laminectomy syndrome causing severe pain that requires a long-term daily around-the-clock opioid analgesic. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The Part D plan has prior authorization requirements that must be met before coverage of this medication will be approved. 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

You requested First Mouth Wash BLM suspension prescribed for unknown diagnosis.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.According to Medicare rules, drugs that are not approved by the Food and Drug Administration are excluded from coverage under Part D. Therefore, we determined that the Part D plan is not required to cover the First Mouth Wash BLM suspension. 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 Tazarotene cream 0.1%, a quantity of 60 grams per 30 days prescribed for atopic dermatitis. 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. At reconsideration level a diagnosis of psoriasis was given. We asked your prescriber to send us information regarding your condition. We also asked for medical records and other documentation to show why you need this medication. We did not receive the documentation requested.It is noted in the medical records that the enrollee has a past medical history of psoriasis. However, the documentation shows your doctor prescribed Tazarotene to treat your atopic dermatitis. The Medicare approved compendia do not support the use of this drug for your condition of atopic dermatitis, as prescribed. A physician reviewed your appeal and determined that the plan is not required to cover Tazarotene.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Viibryd 40 milligram tablet, a quantity of 90 tablets for 90 days. 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. Viibryd 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 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 Midodrine Hydrochloride 2.5 milligram tablet prescribed four times daily for orthostatic hypotension. 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.Midodrine Hydrochloride 2.5 milligram tablet is a generic drug on Tier 3 of the plans formulary. There are no generic drugs of the same type on the lower cost sharing tiers to treat the enrollees diagnosis. 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 the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ipratropium Bromide/Albuterol Sulfate 0.5-3 milligram/3 milliliter nebulizer ampule prescribed for chronic obstructive pulmonary disease. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The drug at issue is for use with a nebulizer in the enrollees home. This is eligible for coverage under Part B. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Myrbetriq Extended Release 25 milligram tablets prescribed for constipation, unspecified. 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 prescriber indicates they prescribed Myrbetriq Extended Release 25 milligram tablets for constipation. 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 Myrbetriq Extended Release tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Jardiance 10 milligram tablets prescribed for diabetes. 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. Jardiance is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat your 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 Jardiance at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tobramycin 300 milligram inhalation ampule prescribed for asthma. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The item at issue is for use with a nebulizer in the enrollees home. This is eligible for coverage under Part B. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Zolpidem Tartrate 5 milligram tablets prescribed for insomnia. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The plan has prior authorization requirements for this drug. 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 a request for coverage of Gralise 600 milligram tablets. The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The submitted medical records indicate that Gralise has been prescribed for idiopathic progressive neuropathy. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prolia 60 milligrams per milliliter pre-filled syringe prescribed to treat osteoporosis.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level.We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication.Your medical records show your doctor prescribed Prolia 60 milligrams per milliliter pre-filled syringe to treat osteoporosis. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. Although medical records were submitted, the prior authorization was not completely filled out. 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 Prolia 60 milligrams per milliliter pre-pre-filled syringe, as the prior authorization criteria was not satisfied. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Acetaminophen-Codeine #3 prescribed daily for unknown diagnosis. 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 you purchased Acetaminophen-Codeine #3 from a network pharmacy for an amount that is less than or equal to the required coinsurance and copayment amount. We reviewed the plans formulary and Evidence of Coverage. In this case, the documentation shows you were in the coverage gap stage when you purchased the Acetaminophen-Codeine #3. The plan paid its share of the cost for the covered drug and you were responsible for your share of the remaining 25%. We determined that the plan is not required to provide additional reimbursement for the Acetaminophen-Codeine #3.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Amitiza 8 microgram capsule, a quantity of 60 capsules per 30 days prescribed for irritable bowel syndrome with diarrhea. 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 and other documentation to show why you need this medication. We did not receive the documentation requested.The documentation shows your doctor prescribed Amitiza to treat your irritable bowel syndrome with diarrhea. However, the Medicare approved compendia do not support the use of this drug for your condition with diarrhea. A physician reviewed your appeal and determined that the plan is not required to cover Amitiza.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Fosamax 70 milligram tablets prescribed as directed 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. 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.  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, 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 Fosamax.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Vraylar 3 milligram capsule prescribed 14 per 14-day supply for Bipolar 1 with manic episodes. 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. The prescriber sent a statement dated 6/18/2021 clarifying the diagnosis and medical history.  Your psychiatrist submitted an attestation correcting the diagnosis. She has prescribed Vraylar to treat your Bipolar 1 with manic episodes. The prescriber states you have tried and failed Seroquel, Abilify, Olanzapine, Depokote, Ziprasidone and Latuda.  Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation satisfies the plans coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Vraylar.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Cyanocobalamin (Vitamin B-12) 1000 microgram per milliliter solution for injection. 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. Cyanocobalamin is a prescription vitamin. Prescription vitamins are excluded from coverage under Medicare Part D. Therefore, the Cyanocobalamin is not eligible for coverage under Medicare Part D. 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

You requested Cialis 20 milligram tablets prescribed for erectile dysfunction. The Part D plan denied your request. 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 record shows that your doctor prescribed Cialis to treat sexual or erectile dysfunction. We determined that the plan is not required to cover the Cialis. Medicare excludes certain drugs from Part D coverage. Cialis is an excluded drug when used to treat sexual or erectile dysfunction; or to treat a condition other than sexual or erectile dysfunction for which the drug has not been approved by the Food and  Drug Administration. The record does not indicate that the plan provides supplemental coverage for Cialis. Therefore, the plan is not required to cover it. 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 Tropicamide 1% solution for unknown diagnosis.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.According to Medicare rules, drugs used as an integral part of a procedure that is a diagnostic or therapeutic service are excluded from coverage under Part D. The record shows Tropicamide solution was used in a therapeutic service as integral part of a procedure. Therefore, it is excluded from coverage under the Part D benefit. However, Tropicamide solution may be covered under Medicare Part B, as a medical benefit. Therefore, we determined that the Part D plan is not required to reimburse you for the Tropicamide solution. 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 Livalo 2 milligram tablets prescribed for hyperlipidemia in an enrollee with arteriosclerotic cardiovascular disease. 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. Your prescriber indicates you have tried Simvastatin, Pravastatin, and Rosuvastatin but they all caused significant myalgias. Your prescriber does not indicate, with support of medical records, why all 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 Livalo.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested prior authorization for Celecoxib 200 milligram capsules prescribed as directed for the enrollees condition. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We did not receive the documentation requested.The documentation submitted does not indicate why your doctor prescribed Celecoxib. Therefore, it cannot be determined if the condition is supported in the Medicare approved compendia for your condition.  A physician reviewed your appeal and determined that the plan is not required to cover Celecoxib.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligram/milliliter auto-injection prescribed every two weeks for mixed hyperlipidemia. 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

You requested Sodium Sulfacetamide-Sulfur 10-5% cleanser for the treatment of Rosacea.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 Sodium Sulfacetamide-Sulfur cleanser because it is on the Medicare Part D list of non-covered drugs. If you purchased drugs/products that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug/product. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Bystolic 5 milligram tablet. 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. Bystolic 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 your appeal and determined that the plan is not required to grant your request for a tiering exception.