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

At issue is Fiorinal 50/325/40-milligram capsule to treat tension headaches. 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.This medication is not on your plan's list of medications. The prescriber has not given a clear and valid medical reason why all medications required by the plan, on that list, did not work for you. This reason has to be in the medical record with details of when you tried those medications. The reason the medications on the formulary won't work or could cause you harm have to be stated. Why the other medications required by the plan will not work must be discussed. Therefore, an exception to the plans formulary coverage criteria is not supported. 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 Corlanor 5 milligram tablet prescribed for postural orthostatic tachycardia syndrome. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The documentation shows Corlanor is prescribed to treat postural orthostatic tachycardia syndrome. However, the Medicare approved compendia do not support the use of this drug for your condition. . This decision does not speak to the medical necessity of this drug for your condition. This decision speaks to whether your plan is required to provide coverage under Medicare rules.A physician reviewed your appeal and determined that the plan is not required to cover Corlanor.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tremfya 100 milligram pen injector prescribed for plaque psoriasis. 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 documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan, with supporting medical documentation, would likely cause harm or not be as effective as the requested drug.  This decision does not speak to the medical necessity of this drug for your condition. This decision speaks to whether your plan is required to provide coverage under Medicare rules. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.. A physician reviewed your appeal and determined that the plan is not required to cover Tremfya.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Qvar Redihaler 80 microgram/actuation powder prescribed for sarcoidosis. 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 Qvar Redihaler is prescribed to treat sarcoidosis. 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 Qvar Redihaler.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Progesterone 100 milligram capsule prescribed for unspecified menopausal and perimenopausal disorder. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we read 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 Progesterone was prescribed to treat unspecified menopausal and perimenopausal disorder. However, the Medicare approved compendia do not support the use of this drug for the enrollee's condition. A physician reviewed your appeal and determined that the plan is not required to cover Progesterone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Potassium Citrate-Citric Acid 100-milligrams-334-milligrams/5-milliliters to treat nephrolithiasis. 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. Additionally, the National Drug Code Directory does not recognize K-Cytra as a Part D drug. Therefore, the requested drug is excluded from coverage.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 Otezla 30 milligram tablets prescribed for moderate to severe plaque psoriasis and psoriatic 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 plan has prior authorization requirements that must be met before coverage of this medication will be approved. 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

At issue is Besivance 0.6% Ophthalmic Solution to treat cortical age-related cataract of the right eye. 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 prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary alternatives required by the plan would likely not be as effective as the requested drug for this condition, and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not medically necessary. 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 Taltz 80 milligrams per milliliter solution auto-injector prescribed to treat plaque psoriasis. 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 records submitted at the reconsideration level.The medical records show the doctor prescribed Taltz 80 milligrams per milliliter solution auto-injector to treat plaque psoriasis. The enrollees 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. This decision does not speak to the medical necessity of this drug for your condition. This decision speaks to whether your plan is required to provide coverage under Medicare rules.A physician reviewed the appeal and determined that the plan is not required to cover Taltz 80 milligrams per milliliter solution auto-injector as the plans prior authorization requirements were not 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 Hetlioz 20 milligram capsule prescribed for non-24 hour sleep-wake disorder. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read 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 asked the 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 medical records show Hetlioz 20 milligram capsule was prescribed to treat non-24 hour sleep-wake disorder. The 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 Hetlioz. 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 Nucynta 50 milligram tablets.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 appeal request is for Nucynta 50 milligram tablets to treat an unknown condition. Upon coverage determination, the Part D plan denied the request stating that the formulary exception requirements were not met.  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 medication. We did not receive the requested documentation.  Without a diagnosis it cannot be established that the requested drug is being prescribed for a medically accepted indication.  As such, the requested drug does not satisfy the definition of a Medicare Part D drug.  A physician reviewed the appeal and determined that the plan is not required to cover Nucynta 50 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Atenolol 25 milligram tablet prescribed for unknown diagnosis.  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 the enrollee purchased Atenolol from an out-of-network Long Term Care facility. Therefore, the plan calculated the cost of the Atenolol outside of the Evidence of Coverage, as an out-of-network generic drug. We determined that the plan is not required to further reimburse the enrollee for the Atenolol.The referenced regulation is applicable only to in-network Long Term Care pharmacies, and therefore is not relevant to the copayments in this case.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Buspirone Hydrochloride 5 milligram tablet prescribed for unknown diagnosis.  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 the enrollee purchased Buspirone Hydrochloride from an out-of-network Long Term Care facility. Therefore, the plan calculated the cost of the Buspirone Hydrochloride outside of the Evidence of Coverage, as an out-of-network generic drug. We determined that the plan is not required to further reimburse the enrollee for the Buspirone Hydrochloride.The referenced regulation is applicable only to in-network Long Term Care pharmacies, and therefore is not relevant to the copayments in this case.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Carbamazepine 200 milligram tablet prescribed for unknown diagnosis.  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 the enrollee purchased Carbamazepine from an out-of-network Long Term Care facility. Therefore, the plan calculated the cost of the Carbamazepine outside of the Evidence of Coverage, as an out-of-network generic drug. We determined that the plan is not required to further reimburse the enrollee for the Carbamazepine.The referenced regulation is applicable only to in-network Long Term Care pharmacies, and therefore is not relevant to the copayments in this case.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Cephalexin 500 milligram tablet prescribed for unknown diagnosis.  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 the enrollee purchased Cephalexin from an out-of-network Long Term Care facility. Therefore, the plan calculated the cost of the Cephalexin outside of the Evidence of Coverage, as an out-of-network generic drug. We determined that the plan is not required to further reimburse the enrollee for the Cephalexin.The referenced regulation is applicable only to in-network Long Term Care pharmacies, and therefore is not relevant to the copayments in this case.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Donepezil HCL 10 milligram tablet prescribed for unknown diagnosis.  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 the enrollee purchased Donepezil HCL from an out-of-network Long Term Care facility. Therefore, the plan calculated the cost of the Donepezil HCL outside of the Evidence of Coverage, as an out-of-network generic drug. We determined that the plan is not required to further reimburse the enrollee for the Donepezil HCL.The referenced regulation is applicable only to in-network Long Term Care pharmacies, and therefore is not relevant to the copayments in this case.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Gabapentin 300 milligram tablet prescribed for unknown diagnosis.  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 the enrollee purchased Gabapentin from an out-of-network Long Term Care facility. Therefore, the plan calculated the cost of the Gabapentin outside of the Evidence of Coverage, as an out-of-network generic drug. We determined that the plan is not required to further reimburse the enrollee for the Gabapentin.The referenced regulation is applicable only to in-network Long Term Care pharmacies, and therefore is not relevant to the copayments in this case.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Ibandronate Sodium 150 milligram tablet prescribed for unknown diagnosis.  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 the enrollee purchased Ibandronate Sodium from an out-of-network Long Term Care facility. Therefore, the plan calculated the cost of the Ibandronate Sodium outside of the Evidence of Coverage, as an out-of-network generic drug. We determined that the plan is not required to further reimburse the enrollee for the Ibandronate Sodium.The referenced regulation is applicable only to in-network Long Term Care pharmacies, and therefore is not relevant to the copayments in this case.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Levothyroxine 50 microgram tablet prescribed for unknown diagnosis.  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 the enrollee purchased Levothyroxine from an out-of-network Long Term Care facility. Therefore, the plan calculated the cost of the Levothyroxine outside of the Evidence of Coverage, as an out-of-network generic drug. We determined that the plan is not required to further reimburse the enrollee for the Levothyroxine.The referenced regulation is applicable only to in-network Long Term Care pharmacies, and therefore is not relevant to the copayments in this case.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Losartan Potassium 25 milligram tablet prescribed for unknown diagnosis.  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 the enrollee purchased Losartan Potassium from an out-of-network Long Term Care facility. Therefore, the plan calculated the cost of the Losartan Potassium outside of the Evidence of Coverage, as an out-of-network generic drug. We determined that the plan is not required to further reimburse the enrollee for the Losartan Potassium.The referenced regulation is applicable only to in-network Long Term Care pharmacies, and therefore is not relevant to the copayments in this case.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Pantoprazole Sodium DR 40 milligram tablet prescribed for unknown diagnosis.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 the enrollee purchased Pantoprazole Sodium DR from an out-of-network Long Term Care facility. Therefore, the plan calculated the cost of the Pantoprazole Sodium DR outside of the Evidence of Coverage, as an out-of-network generic drug. We determined that the plan is not required to further reimburse the enrollee for the Pantoprazole Sodium DR.The referenced regulation is applicable only to in-network Long Term Care pharmacies, and therefore is not relevant to the copayments in this case.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Potassium Chloride ER 10 milliequivalent tablet prescribed for unknown diagnosis.  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 the enrollee purchased Potassium Chloride ER from an out-of-network Long Term Care facility. Therefore, the plan calculated the cost of the Potassium Chloride ER outside of the Evidence of Coverage, as an out-of-network generic drug. We determined that the plan is not required to further reimburse the enrollee for the Potassium Chloride ER.The referenced regulation is applicable only to in-network Long Term Care pharmacies, and therefore is not relevant to the copayments in this case.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Sucralfate 1 gram tablet prescribed for unknown diagnosis.  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 the enrollee purchased Sucralfate from an out-of-network Long Term Care facility. Therefore, the plan calculated the cost of the Sucralfate outside of the Evidence of Coverage, as an out-of-network generic drug. We determined that the plan is not required to further reimburse the enrollee for the Sucralfate.The referenced regulation is applicable only to in-network Long Term Care pharmacies, and therefore is not relevant to the copayments in this case.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Xarelto 15 milligram tablet prescribed for unknown diagnosis.  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 the enrollee purchased Xarelto from an out-of-network Long Term Care facility. Therefore, the plan calculated the cost of the Xarelto outside of the Evidence of Coverage, as an out-of-network generic drug. We determined that the plan is not required to further reimburse the enrollee for the Xarelto.The referenced regulation is applicable only to in-network Long Term Care pharmacies, and therefore is not relevant to the copayments in this case.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Spiriva Handihaler 18 microgram inhalation capsules. 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 documentation indicates that Spiriva Handihaler 18 microgram inhalation capsules have been prescribed for the treatment of asthma. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed in this formulation - Handihaler, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.