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

You requested Bumetanide 1 milligram tablet prescribed for unknown diagnosis. 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 you received Bumetanide as a self-administered drug while in the hospital. According to your plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus your required co-payment amount, and the difference between what the plan normally pays for the drug and what the out-of-network pharmacy charged you. If you pay the full cost of a prescription, then you 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 you paid was not provided. Therefore, we determined that the plan is not required to offer reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Clopidogrel bisulfate 300 milligram tablet prescribed for unknown diagnosis. 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 you received Clpidogrel bisulfate as a self-administered drug while in the hospital. According to your plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus your required co-payment amount, and the difference between what the plan normally pays for the drug and what the out-of-network pharmacy charged you. If you pay the full cost of a prescription, then you 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 you paid was not provided. Therefore, we determined that the plan is not required to offer reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gabapentin 100 milligram capsule prescribed for unknown diagnosis. 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 you received Gabapentin as a self-administered drug while in the hospital. According to your plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus your required co-payment amount, and the difference between what the plan normally pays for the drug and what the out-of-network pharmacy charged you. If you pay the full cost of a prescription, then you 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 you paid was not provided. Therefore, we determined that the plan is not required to offer reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Metoprolol succinate extended release 24 hour 25 milligram tablet prescribed for unknown diagnosis. 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 you received Metoprolol succinate as a self-administered drug while in the hospital. According to your plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus your required co-payment amount, and the difference between what the plan normally pays for the drug and what the out-of-network pharmacy charged you. If you pay the full cost of a prescription, then you 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 you paid was not provided. Therefore, we determined that the plan is not required to offer reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pantoprazole 20 milligram tablet prescribed for unknown diagnosis. 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 you received Pantoprazole as a self-administered drug while in the hospital. According to your plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus your required co-payment amount, and the difference between what the plan normally pays for the drug and what the out-of-network pharmacy charged you. If you pay the full cost of a prescription, then you 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 you paid was not provided. Therefore, we determined that the plan is not required to offer reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Rosuvastatin 20 milligram tablet prescribed for unknown diagnosis. 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 you received Rosuvastatin as a self-administered drug while in the hospital. According to your plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus your required co-payment amount, and the difference between what the plan normally pays for the drug and what the out-of-network pharmacy charged you. If you pay the full cost of a prescription, then you 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 you paid was not provided. Therefore, we determined that the plan is not required to offer reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sertraline 10 milligram tablet prescribed for unknown diagnosis. 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 you received Sertraline as a self-administered drug while in the hospital. According to your plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus your required co-payment amount, and the difference between what the plan normally pays for the drug and what the out-of-network pharmacy charged you. If you pay the full cost of a prescription, then you 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 you paid was not provided. Therefore, we determined that the plan is not required to offer reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Spironolactone 25 milligram tablet prescribed for unknown diagnosis. 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 you received Acetaminophen as a self-administered drug while in the hospital. According to your plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus your required co-payment amount, and the difference between what the plan normally pays for the drug and what the out-of-network pharmacy charged you. If you pay the full cost of a prescription, then you 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 you paid was not provided. Therefore, we determined that the plan is not required to offer reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Symbicort 160/4.5 micrograms/actuation inhalation aerosol to treat chronic bronchitis with restrictive and obstructive lung disease.   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.Symbicort 160/4.5 micrograms/actuation inhalation aerosol 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

At issue is coverage for Hetlioz 20 milligram capsules prescribed for the management of circadian rhythm sleep disorder free run type, non-24-hour sleep-wake disorder. 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. The documentation does not satisfy the plans coverage criteria. The prescriber has addressed the prior authorization criteria on the submitted order form; however, the responses do not satisfy all of the plans requirements for coverage of this medication. During this review, a request was submitted to the prescriber to further address the coverage criteria and to provide supporting medical records. A reply from the prescriber was not received. Therefore, there is insufficient documentation to establish that the requirements for coverage of Hetlioz have been met. 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 Patanase 0.6% solution prescribed one drop two times a day for allergic rhinitis due to pollen. This drug is not on the plan's list of drugs. The Part D plan denied your request.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. 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 records do not support why other drugs on the plans formulary would not work for you. No medical records were provided. A physician reviewed your appeal and determined that the plan is not required to cover Patanase.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Testosterone Cyopionate 200 milligram/milliliter solution 6 per 90 days prescribed for testicular hypofuction. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The prescriber submitted medical records that show Testosterone Cyopionate was prescribed for testicular hypofunction. 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 Testosterone Cyopionate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Freestyle Libre 14-day sensor prescribed for diabetes. 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 glucose monitoring. This is eligible for coverage under Part B. The item is not eligible for Part D coverage.We determined that the plan is not required to cover Freestyle Libre 14 day sensor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine Hydrochloride 5 milligram tablets prescribed daily for unspecified osteoarthritis, unspecified site. The Part D plan auto-forwarded the request.We performed an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The use of the requested drug to treat the provided diagnosis is an off-label use.  The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition.  Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Alprazolam 1 milligram tablets prescribed daily forlumbar muscle spasms. 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 also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Alprazolam to treat your lumbar muscle spasms. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit. A physician reviewed your appeal and  determined that the plan is not required to cover the Alprazolam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for a 90-day supply of Xifaxan 550 milligram tablets prescribed for hepatic encephalopathy. 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. Xifaxan is included in the specialty tier of the plans formulary. The plan limits the drugs in the specialty tier to a recurring 30-day supply. This drug has already been approved for a 30-day supply by the Part D plan. An exception to the quantity limit criteria has not been met. It is noted that the prescriber has submitted a letter at reconsideration stating that he has since written a prescription for a 30-day supply of Xifaxan.A physician reviewed the appeal and determined that the plan is not required to cover a 90-day supply of Xifaxan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Apixaban 5 milligram tablet prescribed for unknown diagnosis. 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 you received the Apixaban from a clinic on March 1, 2020. According to your plan's Evidence of Coverage, if you pay the full cost of a prescription, you 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 you paid for the Apixaban was not provided. Therefore, we determined that the plan is not required to reimburse you.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Novolog 100 milligram/milliliter solution 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 Novolog 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 Novolog. 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 Novolog.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ketorolac compound troche 36 gram for 84 days prescribed for chronic 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. The record shows the Ketorolac compound troche is a compounded drug and each ingredient is reviewed individually. Medicare Part D does not cover non-prescription drugs. Some of the ingredients within the compounded drug are over-the-counter drugs and are not eligible for Part D coverage. We also found that the National Drug Codes submitted for each of the active ingredients are not listed with the Food and Drug Administration as valid codes. Therefore, we determined the plan is not required to cover the compounded drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Novolog 100 unit/milliliter solution administered through your infusion pump for your diabetes. 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 received a reconsideration request.We performed and 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 insulin is being is being used to treat your condition. However, this drug is eligible for coverage under Medicare Part B. The Novolog is being administered with an infusion pump that is covered by Medicare Part B durable medical equipment. Therefore, the drug may be covered by Medicare Part B.We determined that the plan is not required to cover Novolog.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xifaxan 550 milligram tablet prescribed for small intestinal bacterial overgrowth. 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 Xifaxan was prescribed to treat small intestinal bacterial overgrowth. 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 Xifaxan.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Repatha Sureclick 140 milligrams/milliliter prescribed for the enrollees hyperlipidemia with atherosclerotic cardiovascular disease. The Part D plan denied coverage.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 records submitted at the reconsideration level. The enrollee satisfies the plan's coverage criteria. The prescriber submitted a statement and medical records to support the enrollee was prescribed Repatha for continuation of therapy to treat hyperlipidemia. The enrollee has been tried on high-intensity statin therapy and the enrollees low-density lipoprotein cholesterol levels after this treatment regimen remained greater than or equal to 70 milligrams/deciliter. The enrollee was started on Repatha therapy and has documented reduction in low-density lipoprotein cholesterol levels. A physician reviewed your appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Amphetamine/Dextroamphetamine ER 5 milligram capsules prescribed daily for non-specific frontal lobe syndrome and impairments in executive functioning. 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 also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Amphetamine/Dextroamphetamine ER to treat your non-specific frontal lobe syndrome and impairments in executive functioning. However, the Medicare approved compendia do not support the use of this drug for your condition. Therefore, the drug cannot be considered for payment under the Part D benefit.  A physician reviewed your appeal and  determined that the plan is not required to cover the Amphetamine/Dextroamphetamine ER.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil Citrate 20 milligram tablets prescribed for Raynauds phenomenon. 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 Sildenafil because it is a sexual or erectile dysfunction drug prescribed for a non-Food and Drug administration approved use. Erectile dysfunction drugs prescribed for off-label uses are excluded from coverage. 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.