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

At issue is Melatonin 3 milligram capsule/tablet. The Part D Plan denied the request because you purchased drugs through the Veterans Administration hospital. 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.Medicare rules state that coordination of benefits between Part D and Veterans Administration is not allowed. The record shows you are eligible to receive Veterans Administration prescription drug benefits and Part D benefits. However, you cannot use both benefits for a single prescription. In this case, you requested reimbursement for drugs already covered by a Veteran Administration benefit. We determined the Part D plan is not required to reimburse you for any drugs which were already paid for by a Veterans Administration benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Metformin HCL 500 milligram tablet. The Part D Plan denied the request because you purchased drugs through the Veterans Administration hospital. 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.Medicare rules state that coordination of benefits between Part D and Veterans Administration is not allowed. The record shows you are eligible to receive Veterans Administration prescription drug benefits and Part D benefits. However, you cannot use both benefits for a single prescription. In this case, you requested reimbursement for drugs already covered by a Veteran Administration benefit. We determined the Part D plan is not required to reimburse you for any drugs which were already paid for by a Veterans Administration benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Niacin 50 milligram tablet. The Part D Plan denied the request because you purchased drugs through the Veterans Administration hospital. 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.Medicare rules state that coordination of benefits between Part D and Veterans Administration is not allowed. The record shows you are eligible to receive Veterans Administration prescription drug benefits and Part D benefits. However, you cannot use both benefits for a single prescription. In this case, you requested reimbursement for drugs already covered by a Veteran Administration benefit. We determined the Part D plan is not required to reimburse you for any drugs which were already paid for by a Veterans Administration benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Polyethylene glycol 3350 oral powder. The Part D Plan denied the request because you purchased drugs through the Veterans Administration hospital. 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.Medicare rules state that coordination of benefits between Part D and Veterans Administration is not allowed. The record shows you are eligible to receive Veterans Administration prescription drug benefits and Part D benefits. However, you cannot use both benefits for a single prescription. In this case, you requested reimbursement for drugs already covered by a Veteran Administration benefit. We determined the Part D plan is not required to reimburse you for any drugs which were already paid for by a Veterans Administration benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Potassium chloride milliequivalent tablet. The Part D Plan denied the request because you purchased drugs through the Veterans Administration hospital. 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.Medicare rules state that coordination of benefits between Part D and Veterans Administration is not allowed. The record shows you are eligible to receive Veterans Administration prescription drug benefits and Part D benefits. However, you cannot use both benefits for a single prescription. In this case, you requested reimbursement for drugs already covered by a Veteran Administration benefit. We determined the Part D plan is not required to reimburse you for any drugs which were already paid for by a Veterans Administration benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sacubitril 24 milligram/Valsartan 26 milligram tablet. The Part D Plan denied the request because you purchased drugs through the Veterans Administration hospital. 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.Medicare rules state that coordination of benefits between Part D and Veterans Administration is not allowed. The record shows you are eligible to receive Veterans Administration prescription drug benefits and Part D benefits. However, you cannot use both benefits for a single prescription. In this case, you requested reimbursement for drugs already covered by a Veteran Administration benefit. We determined the Part D plan is not required to reimburse you for any drugs which were already paid for by a Veterans Administration benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Simethicone 80 milligram chew tablet. The Part D Plan denied the request because you purchased drugs through the Veterans Administration hospital. 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.Medicare rules state that coordination of benefits between Part D and Veterans Administration is not allowed. The record shows you are eligible to receive Veterans Administration prescription drug benefits and Part D benefits. However, you cannot use both benefits for a single prescription. In this case, you requested reimbursement for drugs already covered by a Veteran Administration benefit. We determined the Part D plan is not required to reimburse you for any drugs which were already paid for by a Veterans Administration benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Spironalctone 25 milligram tablet. The Part D Plan denied the request because you purchased drugs through the Veterans Administration hospital. 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.Medicare rules state that coordination of benefits between Part D and Veterans Administration is not allowed. The record shows you are eligible to receive Veterans Administration prescription drug benefits and Part D benefits. However, you cannot use both benefits for a single prescription. In this case, you requested reimbursement for drugs already covered by a Veteran Administration benefit. We determined the Part D plan is not required to reimburse you for any drugs which were already paid for by a Veterans Administration benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trazadone hydrochloride 50 milligram tablet. The Part D Plan denied the request because you purchased drugs through the Veterans Administration hospital. 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.Medicare rules state that coordination of benefits between Part D and Veterans Administration is not allowed. The record shows you are eligible to receive Veterans Administration prescription drug benefits and Part D benefits. However, you cannot use both benefits for a single prescription. In this case, you requested reimbursement for drugs already covered by a Veteran Administration benefit. We determined the Part D plan is not required to reimburse you for any drugs which were already paid for by a Veterans Administration benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a lower cost tiering exception for Linzess 290 microgram capsules. We received an auto-forwarded reconsideration request from the coverage level. 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. Medical records were requested from your doctor during this review, but not received.Linzess is a brand drug on Tier 4 of your plans formulary. In order to grant a lower cost tiering exception, the records must show that you have tried and failed, or cannot take, the brand drugs of the same type listed on the lower tiers of the plans formulary. However, the submitted documentation lacks medical records from your doctor to show that you have tried the other medications of the same type on the lower tiers of the formulary or that you cannot take them. Therefore, the plan cannot grant a lower cost tiering exception for the Linzess.A physician reviewed your appeal and determined that the Linzess is not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Azasite prescribed for Meibomian gland dysfunction and ocular rosacea. The Part D plan denied your request. 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. Your medical records show your doctor prescribed Azasite to treat your Meibomian gland dysfunction and ocular rosacea. However, the Medicare approved compendia does 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 Azasite. A Part D drug must be for a medically accepted indication as described by Medicare approved compendia.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lorazepam 1 milligram prescribed for Sjogren's disease, benign paroxysmal positional vertigo and burning mouth syndrome. We received a reconsideration request. We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. The record shows Lorazepam was ordered to treat your conditions. However, the Medicare approved compendia do not support the use of this drug for the diagnoses provided. A physician reviewed your appeal and determined that the plan is not required to cover the requested Lorazepam.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lyrica 200 milligram capsule. The Part D Plan denied your request for a tiering exception. 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 available. Lyrica is a non-formulary drug. Per Medicare rules, tiering exceptions are not allowed for a drug that is not on the enrollees formulary. 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 Saxenda 10 microgram/10 milliliter pen prescribed to treat weight gain. The plan denied the request because Medicare excludes Part D coverage of drugs used for the treatment of weight gain or obesity. 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.The record shows you were prescribed Saxenda for the treatment of weight gain. We determined the plan is not required to cover Saxenda because it is excluded from coverage under Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Trijardy Extended Release 1000 milligrams prescribed one tablet daily for diabetes mellitus. The plan denied the appeal because this drug is not listed on your formulary plan (non-formulary). 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. Your medical records show your doctor prescribed Trijardy Extended Release for your diabetes mellitus. This drug is not listed in your plans formulary for your condition. Your doctor did not include medical documentation of the alternative drugs that you have tried that are listed on your plans formulary for your condition, why they did not work, or if they caused adverse effects. Therefore, the requested drug cannot receive a formulary exception.A physician reviewed your appeal and determined that the plan is not required to cover Trijardy Extended Release because the documentation does not show that you have met the coverage criteria for a formulary exception per Medicare rules.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tukysa 150 milligram tablets prescribed as directed for an enrollee with metastatic breast cancer. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. 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 records submitted at the reconsideration level. We requested additional information from the treating prescriber about the enrollees condition. We did not receive the additional documentation. The documentation shows the doctor prescribed Tukysa to treat an enrollee with hormone receptor positive, HER2 positive metastatic breast cancer. The enrollee has been treated with Perjeta, Herceptin, Aromasin, and Faslodex. The current clinical notes indicate the enrollee will be treated with Kadcyla. 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 Tukysa.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Potassium Chloride 10% Liquid (20 milliequivalents per 15 milliliters) to treat hypokalemia. The Part D plan denied your request for a tiering exception. 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. Potassium Chloride 10% Liquid is a generic drug on Tier 4 of the plans formulary. The physician submitted a supporting statement. The prescriber statement indicates the physician had prescribed Potassium Chloride 10% Liquid because the enrollee is unable to take anything orally, and medication must be given by percutaneous endoscopic gastrostomy tube. However, medical records have not been submitted for review. The prescriber has not indicated if all alternatives required by the Plan have been tried and failed, or why the Plans lower tiered drugs would likely not be as effective as the requested drug.  Therefore, a tiering exception to the plans coverage criteria is not supported.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate Mofetil 500 milligram tablets prescribed for chorioretinal inflammation, posterior uveitis and unspecified retinal disorders. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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. We also researched Medicare regulations and Medicare approved compendia. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the enrollees condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.Our Physician Reviewer has determined that the plan is not required to cover Mycophenolate Mofetil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Viibryd 20 mg tablet 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.Viibryd 20 mg tablet is a brand drug on Tier 4 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 Febuxostat 40 milligram tablet prescribed for gout of the ankle and foot. The Part D plan denied your request. We received an expedited 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.Febuxostat is being requested for gout. A prescriber statement was submitted but there are no medical records to support the off-formulary drug. Therefore, an exception to the plans coverage criteria is not supported.A physician reviewed your appeal and determined that the plan is not required to cover Febuxostat.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Otrexup 20 milligrams prescribed as directed for rheumatoid arthritis. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received an expedited 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 records submitted at the reconsideration level. Your medical records show you were prescribed Otrexup for your condition. The plan requires prior authorization criteria for this drug be met before they will cover the requested drug. The records provided does not show the coverage criteria has been met. 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 Otrexup.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amitiza 24 micrograms to treat irritable bowel syndrome, constipation-predominant. 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 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 has not indicated 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 coverage criteria is not supported. Our Physician Reviewers opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Methotrexate 2.5 milligram tablet to treat chronic lymphocytic leukemia. The Part D plan denied the request. We received an auto-forwarded expedited 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.Methotrexate 2.5 milligram tablet is a generic drug on Tier 3 of the plans formulary. The prescriber has not indicated that you have tried all alternatives required by the plan, or why the plans lower tiered drugs would likely not be as effective as the requested drug. 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: Favorable

At issue is Novolog 100 units per milliliter to treat diabetes. 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.The medical record shows the requested drug was being prescribed to treat the provided diagnosis. The medical record also shows the enrollee was no longer using an infusion pump for Novolog. The documentation satisfies the plans coverage criteria.A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Naltrexone Hydrochloride 50 milligram compounded tablets to treat radiculopathy and chronic pain. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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. 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

At issue is a tiering exception request for Eliquis 5 milligram 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.Eliquis 5 milligram 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.