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

At issue is a tiering exception request for Jardiance 25-milligram tablet to treat the enrollees Type 2 diabetes mellitus with hyperglycemia. 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.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.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Aranesp (Albumin free) 40 microgram/0.4 milliliter solution for injection prescribed for renal 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. The record shows the drug is being supplied by the prescriber and administered to the enrollee in the prescribers 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 that the plan is not required to cover the Aranesp (Albumin free) injection. Please consider submitting 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 Phenobarbital-Belladonna Elixr. The Part D Plan denied your request because Medicare Part D does not cover less than effective Drug Efficacy Study Implementation drugs. We received a reconsideration 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 documentation shows the Phenobarbital-Belladonna Elixr is identified as a less than effective Drug Efficacy Study Implementation drug on the Medicare website.We determined that the plan is not required to cover Phenobarbital-Belladonna Elixr. Medicare Part D does not cover less than effective Drug Efficacy Study Implementation drugs. If you purchase drugs that are excluded, you must pay for them out-of-pocket. 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

At issue is Hetlioz 20 milligram capsule prescribed for circadian rhythm disorder, free run type. 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 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.. Your doctor prescribed Hetlioz 20 milligram capsule to treat your circadian rhythm disorder, free run type. 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 Hetlioz. 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 Flector 1.3% patch prescribed for the treatment of glioblastoma. 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 the enrollee was given Flector while in a skilled nursing facility. The facility submitted a claim and the claim processed for an amount that is less than or equal to the required copayment amount. The plans Evidence of Coverage indicates reimbursement is calculated 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 facility charged. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the copay. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Protonix 40 milligram suspension prescribed for the treatment of glioblastoma. 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 the enrollee was given Protonix while in a skilled nursing facility. The facility submitted a claim and the claim processed for an amount that is less than or equal to the required copayment amount. The plans Evidence of Coverage indicates reimbursement is calculated 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 facility charged. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the copay. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is prescribed Pregabalin 75 milligram oral capsule. 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 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 prescriber statement and medical records show your doctor prescribed Pregabalin to treat your pain due to diabetic peripheral neuropathy. However, 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 Pregabalin. The record does not show you have experienced an inadequate treatment response, intolerance, or contraindication to Gabapentin. 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 Rydapt 25 milligram capsules prescribed for acute myeloid leukemia. The Part D plan denied your 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.We determined that the plan is not required to cover Rydapt because the sponsor of the clinical trial was not on the list of qualifying federal agencies/sponsors. Drugs used in clinical trials performed by sponsors that are not qualified agencies/sponsors are excluded from coverage. 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 Esomeprazole Magnesium Packet 40 milligrams prescribed for gastro-esophageal reflux 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. Your prescriber indicates you have tried Prilosec and Pantoprazole for this condition. 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 supportedA physician reviewed your appeal and determined that the plan is not required to cover Esomeprazole Magnesium Packet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Clotrimazole-Betamethasone 1/0.05% cream for rash and other non-specific skin eruption and non-pressure chronic ulcer buttock. 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 Clotrimazole-Betamethasone to treat rash and other non-specific skin eruption and non-pressure chronic ulcer buttock. 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 Clotrimazole-Betamethasone.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac Sodium 1% Gel prescribed to treat osteoarthritis pain of the right knee. 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. We also researched Medicare regulations and reviewed the enrollment data available. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The plan requires that treatment with the requested drug be necessary due to the concern of an intolerance or a contraindication to two oral non-steroidal anti-inflammatory drugs. The medical records submitted indicate that acetaminophen was tried but no indication two oral non-steroid anti-inflammatory drugs were tried. Therefore, the pre-authorization requirements were not satisfied.A physician reviewed your appeal and determined that the plan is not required to cover Diclofenac Sodium 1% Gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dilantin 100 milligram oral capsule. 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. Dilantin is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers to treat the enrollees 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 Lantus 100 units/milliliter vial prescribed for diabetes. 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. Lantus is a brand name drug on Tier 3 of the plans formulary. There are no brand name 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 Forteo solution pen injector 620 micrograms/2.48 milliliter for age-related osteoporosis without current pathological fracture. The Part D plan denied your request because prior authorization requirements were not met. 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 Forteo for age-related osteoporosis without current pathological fracture. 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 Forteo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Reyvow 100 milligram tablets to treat the enrollees condition. The Part D plan denied the request. We received a reconsideration 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.This drug is being 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.Our physician reviewer's opinion is that non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Cyclobenzaprine Hydrochloride 10 milligram tablets prescribed for an unknown condition for the dates of service of January 15, 2021, and January 28, 2021. 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 for Cyclobenzaprine Hydrochloride is approved. A request was submitted to your doctor to provide a diagnosis, to address the plans coverage criteria, and to provide supporting medical records. A reply from the prescriber was not received. Without a diagnosis it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to reimburse the amount paid for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Kesimpta 20 milligrams per 0.4 milliliter auto-injector pen prescribed to treat relapsing remitting multiple 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.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 Kesimpta 20 milligrams per 0.4 milliliter auto-injector pen.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Duloxetine Hydrochloride 20 milligrams as part of a compounded drug prescribed as directed. 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 Duloxetine Hydrochloride to treat your lumbar spinal stenosis with neurogenic claudication and intermittent lumbar radicular 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 Duloxetine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lyrica 100 milligrams as part of a compounded drug prescribed as directed. 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 Lyrica to treat your lumbar spinal stenosis with neurogenic claudication and intermittent lumbar radicular 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 Lyrica.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rabeprazole Sodium 20 milligram tablet prescribed for gastro-esophageal reflux disease without esophagitis. 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 submitted a statement that shows Rabeprazole Sodium 20 milligram tablet was prescribed for gastro-esophageal reflux disease without esophagitis. 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 documentation does 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 Rabeprazole Sodium.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested True metrix glucose test strip 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. We determined that the plan is not required to cover the True metrix glucose test strips because it is not considered a medical supply directly associated with the injection of insulin. Although, this drug is not covered under Part D, it may be covered under Part B. Please submit your request to Medicare Part B. 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 reimbursement for Belbuca 600 microgram film prescribed for pain. The Part D plan denied your request stating a prior authorization was required. 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. Prior authorization is not required for this drug. However, there are no medical records to support the medical necessity for the Belbuca. A tiering exception cannot occur if the drug itself is not found to be medically necessary. In addition, a receipt for payment was not submitted to substantiate the cost of the Belbuca. A physician reviewed your appeal and determined that the plan is not required to approve a tiering exception or reimburse for the Belbuca.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mekinist 2 milligram tablet to treat recurrent high grade papillary serous carcinoma of the ovary. 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 Mekinist to treat recurrent high grade papillary serous carcinoma of the ovary. 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 Mekinist.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metaxalone 400 milligram tablets prescribed to treat right-sided low back 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.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 Metaxalone 400 milligram tablets.