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

At issue is coverage for Sildenafil 20 milligram tablets.  The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication.  We received a reconsideration 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 documentation indicates that Sildenafil has been prescribed for pulmonary hypertension with right ventricle failure and chronic systolic congestive heart failure with left ventricular assist device. However, the Medicare approved compendia do not contain any citations to support the use of the requested medication, as prescribed, for the treatment of the noted conditions. Therefore, the drug is being prescribed for non-medically accepted indications and is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover Sildenafil.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Mycophenolate Mofetil prescribed for lichen planus. 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. The submitted documentation indicates your doctor prescribed Mycophenolate Mofetil for lichen planus and actinic keratosis.  The use of the requested drug to treat the provided diagnoses 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 Sumatriptan Nasal Spray 20 milligrams prescribed to treat migraine headaches. The Part D plan denied your request for a formulary 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. The drug requested is not on the plans formulary. The prescriber states that you tried oral Sumatriptan and Rizatriptan but had significant side effects. However, the records did not state you had tried the alternative nasal spray listed on the formulary. In addition, no medical records were submitted stating why other alternatives required by the plan  would likely not be as effective as the requested drug; and/or would likely cause adverse reaction or other harm. Therefore, an exception to the plan's 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

You requested Ipratropium Bromide-Albuterol Sulfate 0.5-3(2.5) milligram/3 milliliter inhalation solution prescribed for chronic obstructive pulmonary disease. 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 drug at issue is for use with a nebulizer in the enrollees home. This is eligible for coverage under Part B. The drug is not eligible for Part D coverage.We determined that the plan is not required to cover Ipratropium Bromide-Albuterol Sulfate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol sulfate 2.5milligrams/3 milliliter nebulizer solution prescribed as directed for asthma and chronic obstructive pulmonary disease. 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 also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Albuterol sulfate nebulizer solution to treat your asthma. However, we determined that the drug is not eligible for Part D coverage. Drugs which are eligible for Part B coverage are excluded from Part D coverage by Medicare law. Therefore, the drug cannot be considered for payment under the Part D benefit.    We determined that the plan is not required to cover Albuterol sulfate nebulizer solution.You may wish to submit a request for Albuterol sulfate nebulizer solution to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Asenapine 10 milligram sublingual tablets prescribed for bipolar 1 disorder, current or most recent episode hypomanic, unspecified.   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.Asenapine 10 milligram sublingual tablet is a generic drug on Tier 4 of the plans formulary. The prescriber sent a letter dated 4/19/2021 clarifying the medical history and previous drug trials.  Medical records were requested but not provided. 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, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Erythromycin 250 milligram filmtab prescribed three times daily for chronic constipation. 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. We also researched Medicare systems and reviewed the enrollment data available. 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

At issue is Fentanyl Patch 72 hour 100 milligram/hour prescribed for back pain. 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. We also researched Medicare regulations and Medicare approved compendia. Fentanyl Patch is a generic drug on Tier 4 of the plans formulary. The plans formulary includes Methadone Hydrochloride, and Morphine Sulfate on Tier 3 of the plans formulary. Your doctor did not address why these medications would not work for you. All generic drugs on lower tiers have not been tried. 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 Albuterol Sulfate 2.5 milligrams/3 milliliter inhalation solution prescribed for chronic obstructive pulmonary disease. 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 drug at issue is an inhalation solution for use with a nebulizer in the enrollees home. This is eligible for coverage under Part B. The drug is not eligible for Part D coverage.We determined that the plan is not required to cover Albuterol Sulfate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Rivastigmine 24 hour Patch 9.5 milligrams prescribe to treat mild cognitive impairment. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. 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 Rivastigmine Patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Voriconazole 200-milligram tablet to treat fungal pneumonia. The Part D plan denied the request stating that the provided diagnosis is a non-medically accepted indication. 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.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 Repatha Sureclick Solution Auto-Injector 140 milligram/milliliter prescribed to treat hyperlipidemia. 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 prescriber has not specified that all formulary alternatives would be less effective than the requested medication or cause adverse effects. A physician reviewed your appeal and determined that the plan is not required to cover Repatha Sureclick.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Buprenorphine Hydrochloride 8 milligram sublingual tablet to be given for opioid dependence and lumbar degenerative disc disease. 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 records submitted at the reconsideration level.Lenvima is being requested to treat the enrollees condition. The Medicare approved compendia support the use of this drug for this condition. The plan requires the use of the drug for maintenance therapy be limited to enrollees who have experienced a hypersensitivity reaction to Naloxone. The documentation provided shows the enrollee has satisfied the plan's prior approval coverage criteria. A physician reviewed your appeal and determined that the plan is required to cover the Buprenorphine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Febuxostat 80 milligrams to treat gout. The Part D plan denied your request because the documentation did not support an off-formulary 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. The prescriber has provided patient specific clinical rationale stating the enrollee has tried and failed Colchicine, Mitigore, and Allopurinol. However, 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 Probenecid on the plans formulary would not work for the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Febuxostat.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Gengraf 25 milligram capsules prescribed daily following a kidney transplant. 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. We also researched Medicare systems and reviewed the enrollment data available. Your records show your doctor prescribed Gengraf to prevent rejection following a kidney transplant. The Medicare approved compendia support the use of this drug for your condition. The enrollees transplant was not covered by Medicare Part A. Based on the information provided, the drug is not eligible for Part B coverage. Therefore, the drug is eligible for Part D coverage in this case.   A physician reviewed your appeal and determined that the plan is required to cover Gengraf.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Acetylcysteine 200 milligram/milliliter inhalation solution prescribed for bronchiectasis and chronic obstructive pulmonary disease. 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 drug at issue is for use with a nebulizer in the enrollees home. This is eligible for coverage under Part B. The drug is not eligible for Part D coverage.We determined that the plan is not required to cover Acetylcysteine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Verapamil ER PM 300 milligram capsules prescribed for hypertension. 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.Verapamil ER PM 300 milligram capsules is a generic drug on Tier 3 of the plans formulary. 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, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Dupixent 300 milligram/2 milliliter subcutaneous injection prescribed for alopecia areata. 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 indicates your doctor prescribed Dupixent for alopecia areata. The Medicare approved compendia do not support the use of this drug for your condition. 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 Fentanyl Patch 50 micrograms/hour prescribed for 45 patches per 30 days to treat chonic pain. 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. There were no medical records submitted supporting the medical necessity of the amount requested of 45 patches per 30 days which is over the plans quantity limit. In order to establish medical necessity medical records are required. The requested drug, at the quantity requested, is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Fentanyl Patch 45 patches per 30 days.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch prescribed for chronic back pain. 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 information submitted at the reconsideration level. Your physician states he prescribed the Lidocaine patch for your chronic back pain not related to postherpetic neuralgia. The Medicare approved compendia do not support the use of this drug, as ordered, for your condition. As the drug was not 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 Diclofenac Epolamine Patch 1.3% prescribe twice a day for chronic back pain. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. We also researched Medicare regulations and Medicare approved compendia. 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 Diclofenac Epolamine Patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Oxcarbazepine 300 milligram tablets 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 plan submitted documentation that shows you were in the initial coverage stage of the Part D benefit when this drug was purchased. 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 record shows the plan paid its share of the cost for the Oxcarbazepine and the remaining amount was your copay for a tier 2 drug filled at a preferred pharmacy. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Buspirone hydrochloride 7.5 milligram tablets 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 plan submitted documentation that shows you were in the initial coverage stage of the Part D benefit when this drug was purchased. 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 record shows the plan paid its share of the cost for the Buspirone hydrochloride and the remaining amount was your copay for a tier 2 drug filled at a preferred pharmacy. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Acetaminophen 325 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

You requested Aspirin adult low strength 81 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 Aspirin 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.