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

You requested Retaine Flax Softgel for unknown diagnosis.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.According to Medicare rules, over-the-counter drugs are excluded from coverage under Part D. Therefore, we determined that the plan is not required to reimburse you for the Retaine Flax Softgel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 24-26 milligram tablet prescribed two times daily. 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

At issue is Armour Thyroid 120 milligram tablet to treat hypothyroidism. 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.Non-Food and Drug Administration approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Briviact 50 milligram tablet prescribed twice daily for unspecified convulsions and migraines. 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. The physician statement shows your doctor prescribed Briviact to treat your unspecified convulsions and migraines. 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 Briviact.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Clonidine 0.3 milligrams/24 hours transdermal patches prescribed as directed. The Part D plan denied your request for a quantity limit 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. We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this amount of the medication. We did not receive the documentation requested.The documentation available for review does not include medical records showing why the physician prescribed Clonidine to this enrollee. It could not be determined whether the requested drug was prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for Medicare Part D coverage. The quantity limit cannot be addressed.A physician reviewed your appeal and determined that the plan is not required to cover Clonidine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Toprol XL 50 milligram tablet prescribed daily for essential hypertension. 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 Toprol XL.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Bystolic 5 milligram tablet 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. Bystolic is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Febuxostat 40 milligram oral tablet . The Part D plan denied your request for a tiering exception.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.This drug is 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.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 Piqray 300 milligram tablets prescribed as directed for metastatic breast cancer. 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 the doctor prescribed Piqray, in combination with Anastrazole, to treat hormone receptor-positive, human epidermal growth factor receptor 2-negative metastatic breast cancer with PIK3CA mutation. The enrollee was initially diagnosed with stage II breast cancer in 1999 and was treated with chemotherapy and radiation, as well as antiestrogen therapy. In 2015, the enrollee was found to have metastatic disease. The enrollee received systemic therapy with Ibrance/Letrozole, Faslodex, Capecitabine, and most recently, Tamoxifen. Despite treatment, the enrollee has experienced disease progression. The prescriber submitted medical literature for review. However, the Medicare approved compendia do not support the use of Piqray, in combination with Anastrazole, for the treatment of the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Piqray.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tobramycin 300 milligram/5 milliliters inhalation solution, administered via nebulizer, prescribed for bronchiectasis with chronic pseudomonas aeruginosa infection. 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 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. We also researched Medicare systems and reviewed the enrollment data available.Based on the information provided, we determined the drug may be eligible for coverage under Part B under Medicare rules.  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 Apidra 100 unit injector prescribed for diabetes mellitus. 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. 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 all other drugs, for your condition, on the plans formulary would not work for you. There is no supporting evidence that all the plans formulary, alternative drugs, have been tried.A physician reviewed your appeal and determined that the plan is not required to cover Apidra.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Simponi 100 milligram/milliliter injection prescribed for hidradenitis suppurativa. 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 Simponi to treat your hidradenitis suppurativa. 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 Simponi.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Temazepam 30 milligram capsule prescribed nightly for insomnia. 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. Your medical records show your doctor prescribed Temazepam to treat your insomnia. 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 Temazepam. This drug is considered a high risk medication in patients over 65. There is no evidence that you have tried or have a contraindication to the non high risk drug, doxepin. 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

At issue is a request for coverage of Zolpidem Tartrate 10 milligram tablets prescribed for insomnia. The Part D plan denied the request. We received the case to perform an independent and de novo review. 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 Part D plan has prior authorization requirements that must be satisfied before Zolpidem Tartrate is covered. During this review, a prescriber statement and supporting medical records were requested from the prescriber to fully address the plans coverage requirements. The prescriber has not sufficiently addressed, with support of medical records, the issues regarding this high-risk medication, and why alternative safer medications could not be used. The prescriber did not respond to our request.The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dronabinol 2.5 milligram capsules prescribed for nausea, anorexia and weight loss. 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 Dronabinol to treat your nausea, anorexia and weight loss. 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 Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vraylar 1.5 milligram capsule prescribed for major depressive disorder. 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 Vraylar to treat your major depressive disorder. 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 Vraylar.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested TDAP vaccine. 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 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 record shows you received the TDAP vaccine December 21, 2020. The record also includes valid proof of payment for reimbursement. However, this drug may be eligible for coverage under Medicare Part B. Part D will cover vaccines except those that qualify for Part B. Tetanus is covered under Part B if given as a treatment for a wound, but if given as prophylaxis it is covered under Part D. There were no medical records provided to determine if the vaccine was given for treatment or for prophylaxis. Therefore, it cannot be determined if the requested drug was prescribed for a medically accepted indication supported by the Medicare approved compendia. As such, the requested drug is not eligible for coverage under Medicare Part D. We determined that the plan is not required to reimburse TDAP vaccine. This drug may be eligible for coverage under Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Valacyclovir Hydrochloride 1000 milligram oral tablets. 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. We reached out to you and your prescriber to send us information regarding your condition and for medical records or other documentation to show why you need this medication. We were unable to reach you or your prescriber and therefore did not receive the documentation required.The documentation shows valid proof of payment. However, there was no diagnosis provided. In addition, no medical records were submitted for review to support a diagnosis. Therefore, it cannot be determined if the requested drug was prescribed for a medically accepted indication supported by the Medicare approved compendia. As such, the requested drug is not eligible for coverage under the Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to reimburse Valacyclovir Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Nuedexta 20-10 milligram capsule prescribed for pseudobulbar affect. 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 medical records show your doctor prescribed Nuedexta to treat your pseudobulbar affect. 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 Nuedexta. The plan states you must be diagnosed with amyotrophic lateral sclerosis or multiple sclerosis. 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 Albuterol Sulfate 2.5 milligram per 3 milliliter vial prescribed daily for six days for chronic obstructive pulmonary disease. 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. The record shows Albuterol Sulfate was prescribed to treat chronic obstructive pulmonary disease exacerbation. The requested drug is being used via nebulizer. According to Medicare rules, Medicare Part B pays for the rental and purchase of durable medical equipment. Payment will also be made under Medicare Part B for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals, which must be put directly into the equipment to achieve the therapeutic benefit of the durable medical equipment. Therefore, this drug may be eligible for coverage under Medicare Part B. We determined that the plan is not required to cover Albuterol Sulfate vials.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Ozempic 2 milligram/1.5 milliliter solution pen injector 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. Ozempic 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 Tolsura 65 milligram capsules prescribed as two capsules by mouth 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. This drug is not included on your plans formulary. Per Medicare rules, non-formulary drugs are 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 Tymlos Solution Pen-Injector prescribed for osteoporosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data 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 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 Tymlos Solution Pen-Injector.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Envarsus XR 1 milligram tablets prescribed daily for the prophylaxis of lung transplant rejection. 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. Envarsus XR 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.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 Travatan Z Eye Drops to treat bilateral low-tension glaucoma. The Part D plan denied the request. The requested drug is not on the plans formulary. 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 that your prescriber ordered Travatan Z Eye Drops to treat your bilateral low-tension glaucoma. We asked the prescriber to send us a prescriber statement and medical records. We received the documentation and included it in our review. The documentation included an office visit note dated December 12, 2019. 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 supported.Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rytary ER 36.25 milligram-145 milligram 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. 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.