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

At issue is Spravato 84 milligram dose pack prescribed for major depressive disorder. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows Spravato is being prescribed to the enrollee for treatment of major depressive disorder. Medicare law specifically excludes coverage for any drug for which payment would be available under Medicare Parts A or B for that individual. Medicare Part B pays for services and supplies incident to the service of a physician (or other practitioner). Spravato is a type of drug that must be administered under direct observation of a health care provider and monitored for at least two hours after administration. The Food and Drug Administration has mandated a Risk Evaluation and Mitigation Strategy for Spravato. This strategy requires that Spravato be only dispensed and administered to patients in a medically supervised healthcare setting that monitors the enrollee. We determined that the drug is eligible under Medicare Part B. Therefore, the Part D plan is not required to cover Spravato. 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

You requested Freestyle Libre 14 day reader device prescribed for multiple diagnoses. 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 Freestyle Libre 14 day reader device because it is not considered a medical supply directly associated with the injection of insulin. Although, this supply 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 supply. 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 Ilaris 150 milligram per milliliter vial for subcutaneous injection. 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 documentation indicates that Ilaris has been prescribed for the treatment of pyodermagangrenosum. 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 Ilaris.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rytary ER 23.75/95 milligram tablets prescribed as directed. 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. Rytary ER 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. 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 Oxycontin 60 milligram tablets prescribed to treat chronic pain syndrome and myalgia.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 Oxycontin 60 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Diltiazem Hydrochloride ER 120 milligram coated beads capsules prescribed as directed. 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. Diltiazem Hydrochloride ER 120 milligram coated bead capsule is a generic drug on Tier 3 of the plans formulary. The medical records do not support that all drugs available on lower tiers to treat the enrollees condition have been tried or deemed contraindicated. 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: Favorable

At issue is Qutenza 8% patch 2 per 30 days for treatment of neuropathic pain associated with diabetic neuropathy. 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 records submitted at the reconsideration level.The medical records show your doctor prescribed Qutenza 8% patch to treat your neuropathic pain associated with diabetic neuropathy, a medically accepted indication. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The records show you had tried and failed the medication Gabapentin. The documentation provided shows the plan's coverage criteria have been satisfied.A physician reviewed your appeal and determined that the plan is required to cover Qutenza.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Calcipotriene Betamethasone Dipropionate prescribed for an 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. The record shows the plan reprocessed a claim for the Calcipotriene Betamethasone Dipropionate and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nitrofurantoin Macrocrystal 50 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. 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 Nitrofurantoin Macrocrystal from a preferred pharmacy 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 pharmacy charged you. The plan paid its share of the cost for the covered drug and you were responsible for the copay. We determined your copay for Nitrofurantoin Macrocrystal was correctly calculated and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Flovent HFA 220 microgram/actuation aerosol prescribed as directed. 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.Flovent HFA 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 Rhopressa 0.02 percent eye drops prescribed as directed. 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. Rhopressa 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

You requested Budesonide 0.5 milligram/2 milliliter ampul-neb prescribed for chronic obstructive pulmonary 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. The record shows Budesonide is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover Budesonide. 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 Estradiol 0.025 milligram per 24 hour twice weekly (TW) patch prescribed twice weekly for low estrogen level. 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. 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. A physician reviewed the appeal and determined that the plan is not required to cover Estradiol twice weekly patches.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Taltz 80 milligrams/milliliter auto-injector subcutaneous solution prescribed as directed for psoriasis. 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. The documentation indicates you have only tried and failed Otezla. 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 Taltz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Shingles vaccine prescribed for vaccination. 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 requested the plan to reimburse you for a shingles vaccine. However, you did not indicate the National Drug Code for the drug. Therefore, the plan did not approve coverage. The National Drug Code has since been provided. However, 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 vaccine was not provided. Therefore, we determined that the plan is not required to reimburse you without proof of payment.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lorazepam 1 milligram tablets prescribed for tremors in an enrollee with Parkinsons 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 prescriber indicates the enrollee has a history of Parkinsons disease and tremors with the requested medication being used long-term since March 2018. Medicare approved compendia do not support the use of this drug for these conditions.  A physician reviewed your appeal and determined that the plan is not required to cover Lorazepam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 24-26 milligram tablets. 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.Entresto 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

You requested Tacrolimus 100% powder prescribed for unknown diagnosis. The 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.According to Medicare rules, drugs that fall into the category of bulk powders are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover the Tacrolimus powder. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Carisoprodol 350 milligram tablet prescribed daily for other muscle spasm. The Part D plan did not make a timely decision. We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The documentation shows the doctor prescribed Carisoprodol 350 milligram tablet to treat the enrollees other muscle spasm omnia. However, the Medicare approved compendia do not support the use of this drug for this unspecified condition. A physician reviewed this appeal and determined that the plan is not required to cover Carisoprodol 350 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha Sureclick 140 milligram/milliliter auto-injector prescribed for 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 Praluent would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Epinephrine 0.3 milligram/0.3-milliliter auto injector prescribed as needed for anaphylaxis. 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. Epinephrine 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. 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 a formulary exception request for Zolpidem Tartrate 12.5 milligram ER tablets. 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.The submitted documentation did not include medical records or a supporting statement. A request for information was sent to your physician. Medical records and a supporting statement were not received. Therefore, as it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested BD Pen Needle/Mini/Ultra Fine 31 gram X 5 millimeter prescribed for an 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. The record shows the plan reprocessed a claim for the BD Pen Needles and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Sevelamer Carbonate 800 milligram tablet prescribed 360 tablets per 30 days for hyperphosphatemia while on dialysis. 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 records show the physician prescribed Sevelamer Carbonate to treat your hyperphosphatemia. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of the requested drug for your condition. Sevelamer carbonate is a phosphate binder indicated for the control of serum phosphorus in patients with chronic kidney disease on dialysis.The records show that you cannot take other drugs on your plans formulary for your condition. Specifically, Auryxia caused iron overload and calcium acetate is no longer recommended.A physician reviewed your appeal and determined that an exception can be granted to cover the drug that is not on your plans formulary. Therefore, the plan is required to cover Sevelamer Carbonate.
Appeal type: Prescription Drug
Decision: Favorable

You requested Budesonide 3 milligram oral capsules prescribed three capsules daily. 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 initial determination the diagnoses of unspecified ulcerative colitis, non-infective gastroenteritis, diarrhea, and rectal bleeding were given. At redetermination the physician submitted a supporting statement and medical records that show Budesonide was prescribed to treat microscopic colitis confirmed by colonoscopy biopsy microscopic results of chronic colitis with mild activity and mild effacement of architecture.  DrugDex, a Medicare approved compendium, identifies microscopic colitis as a medically accepted indication.   A physician reviewed your appeal and determined that the plan is required to cover Budesonide 3 milligram oral capsules and an exception to the prior authorization criteria is granted.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Estrogen-Methyltestosterone 1.25-2.5 milligram tablet prescribed for menopausal syndrome. 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 Estrogen-Methyltestosterone 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 Estrogen-Methyltestosterone. 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.