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

You requested Afinitor 10 milligram tablet prescribed for metastatic estrogen receptor positive, human epidermal growth factor receptor 2 negative left 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 records show Afinitor 10 milligram tablet was prescribed to treat the enrollees metastatic estrogen receptor positive, human epidermal growth factor receptor 2 negative left breast cancer. The records submitted indicate that the enrollee is post-menopasual and will be using Afinitor in combination with Letrozole. Afinitor will not be utilized with Exemestane or Faslodex, as required.An oncologist reviewed your appeal and determined that the plan is not required to cover Afinitor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humira Citrate-free 40 milligrams per 0.4 milliliters syringe kit prescribed to treat psoriatic arthritis. The Part D plan denied the appeal 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 records submitted at the reconsideration level.The documentation shows the doctor prescribed Humira Citrate-free 40 milligrams per 0.4 milliliters syringe kit to treat psoriatic arthritis. The enrollees plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The prescriber indicates Humira will be taken in combination with another biologic disease modifying antirheumatic drug. The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed the appeal and determined that the plan is not required to cover Humira Citrate-free 40 milligrams per 0.4 milliliters syringe kit, as the prior authorization requirements have not been satisfied. 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 Clobetasol 0.05% shampoo prescribed for seborrheic dermatitis. 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.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 the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the enrollee.  We received some of the documentation and included it in our review.   The prescriber was asked to answer questions about the requested drug and the prescriber was informed that medical records alone were not a substitution for completion of the form.  The prescriber did not answer any of the questions on the form but instead just sent medical records.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 documentation does not support why other drugs 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 Clobetasol shampoo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Promethazine Hydrochloride 6.25 milligrams per 5 milliliters oral solution to treat nausea related to gastroesophageal reflux disease, esophagitis, and epigastric abdominal pain. The Part D plan denied the appeal 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 shows the doctor prescribed Promethazine Hydrochloride 6.25 milligrams per 5 milliliters oral solution to treat nausea related to gastroesophageal reflux disease, esophagitis, and epigastric abdominal pain. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition.A physician reviewed the appeal and determined that the plan is not required to cover Promethazine Hydrochloride 6.25 milligrams per 5 milliliters oral solution.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage Saxenda 18 milligram/3 milliliter pen injector prescribed for polycystic ovarian syndrome. The Part D plan denied your 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 determined that the plan is not required to cover Saxenda because it  was used to treat obesity. Drugs to treat weight gain (promote weight loss) are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, the enrollee must pay for them. This decision does not address the medical necessity or appropriateness of Saxenda. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% Patch to treat pain secondary to degeneration lumbar intervertebral disc. 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.We asked your prescriber to send us a prescriber statement, documentation related to your pain, and medical records. However, we did not receive the information.At reconsideration, a diagnosis of pain left thigh was added. The use of the requested drug to treat the provided diagnoses are 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 these conditions. 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

At issue is a request for coverage of Nuedexta 20-10 milligram capsules. The Part D plan denied the request stating the prior authorization requirement that the enrollee must have amyotrophic lateral sclerosis, multiple sclerosis, Parkinson's disease, stroke, or traumatic brain injury was not met. 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 indicates that the requested drug has been prescribed for the treatment of pseudobulbar affect, which is a medically accepted indication outlined in the Medicare approved compendia. At reconsideration, the prescriber has noted that the enrollee does have a history of stroke. However, the plan has additional prior authorization requirements that have to be met before coverage Nuedexta will be allowed. During this review, a request was submitted to the prescriber to address the plans additional prior authorization requirements and to provide supporting medical records. The prescriber did not respond to the request. Therefore, the available documentation does not validate that the plans prior authorization criteria have been satisfied. As such, the drug is not eligible for coverage. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq 50 milligram extended release tablets prescribed for the enrollees condition. The Part D plan denied the request for a tiering exception.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.Myrbetriq 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 the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Shingrix vial kit prescribed for unknown diagnosis. 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 the enrollee purchased Shingrix 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 the required deductible, or copayment amount, and minus the difference between what the plan normally pays for the drug and what the pharmacy charged. The plan paid its share of the cost for the covered drug and the enrollee was responsible for the copay. We determined the copay for Shingrix was calculated correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rayaldee 30 microgram extended release capsules prescribed for hyperparathyroidism associated with chronic kidney 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 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 for the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Rayaldee.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Glyxambi 25 milligram-5 milligram tablets prescribed for the enrollees condition. The Part D plan denied the request for a tiering exception.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.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 the appeal and determined that the plan is not required to grant the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanz 5 milligram tablets prescribed as directed for arthropathic psoriasis, unspecified and psoriatic arthritis. 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.Your medical records show your doctor prescribed Xeljanz to treat your arthropathic psoriasis, unspecified and psoriatic arthritis. 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. The enrollee is currently receiving Stelara, which is excluded in the prior authorization policy criteria for use of two therapeutic immunomodulators used together.A physician reviewed your appeal and determined that the plan is not required to cover Xeljanz.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Rexulti 1 milligram tablets prescribed for anxiety. 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.The submitted documentation indicates the prescriber ordered Rexulti for anxiety. The Medicare approved compendia do not support the use of the drug at issue for the enrollees condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.  Medical records were requested and were not provided. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Ensure Max Protein liquid 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 Ensure Max Protein liquid. 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 Gammagard 10% solution prescribed for the treatment of hypogammaglobulinemia and common variable immunodeficiency. 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 the doctor prescribed Gammagard to be administered to the enrollee in the home for the treatment of hypogammaglobulinemia and common variable immunodeficiency. Intravenous immune globulin may be allowed under Part B in the home for a diagnosis of common variable immunodeficiency. We determined that the Medicare Part D plan is not required to cover Gammagard. 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. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Hydrocortisone-Pramoxine 2.5-1% cream prescribed for unknown diagnosis. 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 the Hydrocortisone-Pramoxine 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 Hydrocortisone-Pramoxine. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyzulta 0.024% eye drops prescribed for primary open angle glaucoma. 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 for the enrollee. A physician reviewed your appeal and determined that the plan is not required to cover Vyzulta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Budesonide Suspension 0.5milligram/2 milliliter. 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 used in a nebulizer and the documents support it will be used in a private residence. This drug is not eligible for coverage under Part D drug benefits. However, this drug may be covered under Medicare Part B benefits. We determined that the plan is not required to cover Budesonide Suspension.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Acetylcysteine 200 milligram/milliliter vial prescribed 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 Acetylcysteine 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 Acetylcysteine. 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 Prevident 5000 Sensitive 1.1/5% paste prescribed for unspecified periodontal disease and unspecified heart 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 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 asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication was needed. We did not receive the documentation requested.The doctor prescribed Prevident 5000 Sensitive paste to treat the enrollees unspecified periodontal disease and unspecified heart disease. At reconsideration a diagnosis of severe sensitivity was given. However, no medical records were provided by the prescriber to support this diagnosis. It could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the plan is not required to cover Prevident 5000 Sensitive paste.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for reimbursement for Hydrocodone-Acetaminophen 7.5-325 milligram tablets purchased on July 21, 2021, which have been prescribed for chronic pain due to rheumatoid arthritis. 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 ordered 180 tablets per 90 days of Hydrocodone-Acetaminophen 7.5-325 milligram tablets. While the plan stated in the denial letter that the drug is limited to a 90-day supply, the plans formulary shows that Hydrocodone-Acetaminophen is actually limited to a recurring 30-day supply. An exception to the quantity limit criteria is not supported. A physician reviewed the appeal and determined that the plan is not required to cover more than a recurring 30-day supply of the requested drug. Therefore, reimbursement is not covered for the drug already purchased.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a formulary exception for potassium chloride extended-release 20 milliequvalent tablets prescribed to treat hypokalemia.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 doctor prescribed potassium chloride extended-release 20 milliequivalent tablets (generic) to treat hypokalemia. Potassium chloride extended-release 20 milliequivalent tablet is on the plans formulary. There are no prior authorization criteria. Therefore, the requested drug is eligible for coverage under Medicare Part D.A physician reviewed the appeal and determined that the plan is required to cover the generic form of potassium chloride extended-release 20 milliequivalent tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Topiramate 100 milligram tablet prescribed to treat obesity. 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 you were prescribed Topiramate for the treatment of obesity. We determined the plan is not required to cover Topiramate because it is excluded from coverage under Part D. If you purchased drugs/products that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug/product. It only establishes that payment cannot be made under the Medicare Part D benefit.