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

At issue is a request for coverage of Sucralfate 1 gram per 10 milliliter suspension prescribed for gastritis. The Part D plan denied the request for coverage.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. Sucralfate suspension is not included in the plans formulary (list of covered drugs). The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why the formulary alternatives included in the plan to treat the enrollees condition would likely not be as effective as the requested drug and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Protonix DR 40 milligram tablet prescribed twice daily for gastroesophageal reflux disease. 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 the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The medical records show the physician prescribed Protonix to treat your gastroesophageal reflux disease. The following citation was referenced in DrugDex, a Medicare approved compendium, and supports the use of the requested drug for your condition. Pantoprazole is indicated for maintenance of healing erosive esophagitis and reduction in relapse rates of daytime and nighttime heartburn symptoms in adult patients with gastroesophageal reflux disease.  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.A physician reviewed your appeal and determined that an exception can be granted to cover the drug that is not on the plans formulary. Therefore, the plan is required to cover Protonix.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Butalbital-Aspirin-Caffeine 50-325-40 milligram capsules. 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. The submitted medical records indicate that Butalbital-Aspirin-Caffeine has been prescribed for the treatment of migraine without aura and without status migrainosus, not intractable. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, 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.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Norditropin Flexpro 5-milligrams/1.5-milliliter SC SOPN to treat hypopituitarism. 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 Norditropin Flexpro to treat the Enrollees hypopituitarism. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided supports the Enrollee has satisfied the plan's coverage criteria.A physician reviewed the appeal and determined that the plan is required to cover Norditropin Flexpro. The prescriber has documented that the Enrollee has multiple pituitary growth hormone deficiencies, which satisfies the plans coverage criteria.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Combigan 0.2-0.5% eye drop solution prescribed every 12 hours for 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. We asked the enrollees prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needed the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for the enrollee. However, we did not receive the documentation.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. 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. A physician reviewed the enrollees appeal and determined that the plan is not required to cover Combigan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is prescribed Fluorouracil 5% cream. 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.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.Your medical records show your doctor prescribed Fluorouracil to treat your actinic keratosis. 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 Fluorouracil cream. 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 Calcitriol 0.5 microgram oral capsule. 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 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.There was no diagnosis given at initial determination. No medical records were submitted for review. 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 prior authorization requirements were not addressed because the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Calcitriol.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Insulin Lispro 100 unit/ml solution pen 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 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 the medication. Specifically, we asked for records to show why other medications on the plan's formulary would not work for you. However, we did not receive the documentation.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 you. A physician reviewed your appeal and determined that the plan is not required to cover Insulin Lispro.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Megestrol Acetate 400 milligram/10 milliliter oral suspension prescribed for moderate protein-calorie malnutrition. 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. 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 documentation shows your doctor prescribed Megestrol Acetate to treat your moderate protein-calorie malnutrition. 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 Megestrol Acetate.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollee requested Acetaminophen Extra Strength 500 milligram tablet. The Part D plan denied the Enrollees 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 received Acetaminophen as a self-administered drug in the hospital. According to Medicare rules, drugs that are considered over-the-counter are excluded from coverage under Part D. Acetaminophen is on Medicares excluded list of drugs because it is an over-the-counter medication. Therefore, we determined that the Part D plan is not required to cover or reimburse the Enrollee for Acetaminophen.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollee requested Celecoxib 200 milligram capsule. The Part D plan denied the Enrollee's 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 the Enrollee received Celecoxib as a self-administered drug in the hospital. According to the plan's Evidence of Coverage, if you pay the full cost of a prescription, the Enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The Enrollee provided a hospital statement showing the drugs that were self-administered and the amount charged for each. However, proof of Enrollee payment in the form of a receipt was not provided. Therefore, we determined that the plan is not required to reimburse the Enrollee for the Celecoxib.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollee requested DOK (docusate sodium) 10 milligram capsule. The Part D plan denied the Enrollees 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 received DOK as a self-administered drug in the hospital. According to Medicare rules, drugs that are considered over-the-counter are excluded from coverage under Part D. DOK is on Medicares excluded list of drugs because it is an over-the-counter medication. Therefore, we determined that the Part D plan is not required to cover or reimburse the Enrollee for DOK.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollee requested Driminate 50 milligram tablet. The Part D plan denied the Enrollees 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 received Driminate as a self-administered drug in the hospital. According to Medicare rules, drugs that are considered over-the-counter are excluded from coverage under Part D. Driminate is on Medicares excluded list of drugs because it is an over-the-counter medication. Therefore, we determined that the Part D plan is not required to cover or reimburse the Enrollee for Driminate.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollee requested Famotidine maximum strength 20 milligram tablet. The Part D plan denied the Enrollees 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 received Famotidine as a self-administered drug in the hospital. According to Medicare rules, drugs that are considered over-the-counter are excluded from coverage under Part D. Famotidine is on Medicares excluded list of drugs because it is an over-the-counter medication. Therefore, we determined that the Part D plan is not required to cover or reimburse the Enrollee for Famotidine.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollee requested Gabapentin 300 milligram capsule. The Part D plan denied the Enrollee's 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 the Enrollee received Gabapentin as a self-administered drug in the hospital. According to the plan's Evidence of Coverage, if you pay the full cost of a prescription, the Enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The Enrollee provided a hospital statement showing the drugs that were self-administered and the amount charged for each. However, proof of Enrollee payment in the form of a receipt was not provided. Therefore, we determined that the plan is not required to reimburse the Enrollee for the Gabapentin.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollee requested Hydralazine HCL 10 milligram tablet. 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 the Enrollee received Hydralazine HCL as a self-administered drug in the hospital. According to the plan's Evidence of Coverage, if you pay the full cost of a prescription, the Enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The Enrollee provided a hospital statement showing the drugs that were self-administered and the amount charged for each. However, proof of Enrollee payment in the form of a receipt was not provided. Therefore, we determined that the plan is not required to reimburse the Enrollee for the Hydralazine HCL.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollee requested Irbesartan 75 milligram tablet. The Part D plan denied the Enrollee's 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 the Enrollee received Irbesartan as a self-administered drug in the hospital. According to the plan's Evidence of Coverage, if you pay the full cost of a prescription, the Enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The Enrollee provided a hospital statement showing the drugs that were self-administered and the amount charged for each. However, proof of Enrollee payment in the form of a receipt was not provided. Therefore, we determined that the plan is not required to reimburse the Enrollee for the Irbesartan.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollee requested Premarin 0.625 milligram/gram cream. The Part D plan denied the Enrollee's 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 the Enrollee received Premarin as a self-administered drug in the hospital. According to the plan's Evidence of Coverage, if you pay the full cost of a prescription, the Enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The Enrollee provided a hospital statement showing the drugs that were self-administered and the amount charged for each. However, proof of Enrollee payment in the form of a receipt was not provided. Therefore, we determined that the plan is not required to reimburse the Enrollee for the Premarin.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollee requested Robafen Cough 15 milligram capsule. The Part D plan denied the Enrollees 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 received Robafen as a self-administered drug in the hospital. According to Medicare rules, drugs that are considered over-the-counter are excluded from coverage under Part D. Robafen is on Medicares excluded list of drugs because it is an over-the-counter medication. Therefore, we determined that the Part D plan is not required to cover or reimburse the Enrollee for Robafen.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollee requested Synthroid 88 microgram tablet. The Part D plan denied the Enrollee's 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 the Enrollee received Synthroid as a self-administered drug in the hospital. According to the plan's Evidence of Coverage, if you pay the full cost of a prescription, the Enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The Enrollee provided a hospital statement showing the drugs that were self-administered and the amount charged for each. However, proof of Enrollee payment in the form of a receipt was not provided. Therefore, we determined that the plan is not required to reimburse the Enrollee for the Synthroid.
Appeal type: Prescription Drug
Decision: Unfavorable

Sodium Sulfacetamide-Sulfur 10-5% (w/v) lotion prescribed for unknown diagnosis. The Part D plan denied the Enrollees 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 determined that the plan is not required to cover or reimburse for the Sodium Sulfacetamide-Sulfur lotion because this drug is excluded from coverage under Medicare Part D. According to the Food and Drug Administration, Sodium Sulfacetamide-Sulfur lotion is a non-prescription or over the counter drug not eligible for Part D coverage. 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

The Enrollee requested Nexletol 180 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the Enrollees 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 the Enrollee was 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 the Enrollee. The record shows the plan paid its share of the cost for the Nexletol and the remaining amount was the Enrollees copay. We determined that Nexletol was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

The Enrollee requested Pradaxa 75 milligram tablet prescribed for unknown diagnosis. The Part D plan denied the Enrollees 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 the Enrollee paid full price for the Pradaxa at the pharmacy. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, documentation was provided showing the Medicare contracted price for the prescription was provided to the pharmacy and the Enrollee was responsible for the copay. The plan will only reimburse up to the contracted price of the drug. We determined the plan calculated reimbursement correctly and is not required to offer additional reimbursement.