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

At issue is Repatha Sureclick 140-milligram/milliliter pen injector to treat primary 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 reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The documentation does not satisfy the plans coverage criteria.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 tiering exception request for Bystolic 10-milligram tablet to treat essential hypertension. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted including the case file from the plan and any information submitted at the reconsideration level.This drug is being 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 reviewer determined that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Phentermine Hydrochloride 37.5-milligram tablet to treat weight gain. The Part D plan denied the 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 Phentermine because it was used to treat obesity. Drugs to treat anorexia, weight loss, or weight gain are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Benztropine Mesylate 1-milligram tablet to treat primary focal hyperhidrosis, palms associated with use of Suboxone. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including 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 diagnosis. Therefore, the requested drug(s) 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 Octagam 10 percent vial to treat chronic inflammatory demyelinating polyneuritis. The case was auto-forwarded by the plan.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The requested drug is not on the plans formulary. 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 alternative drugs provided on the plans formulary list would likely not be as effective for this diagnosis, and/or would likely cause adverse reaction(s) or other harm.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 tiering exception request for Xiidra to treat dry eye syndrome. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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 being 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 request and determined that non-formulary drugs are not eligible for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tretinoin 0.05 percent topical cream to treat facial milia cysts. The Part D plan denied the request for coverage because drugs used for cosmetic purposes are excluded from Part D coverage. We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The prescriber has noted at reconsideration that the enrollees facial papules include both steatocystomas and millia and the Tretinoin cream has been prescribed for the treatment of both conditions. However, both of the noted conditions are off-label uses for the requested drug. 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 being prescribed for non-medically accepted indications and 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 Dupixent 200-milligrams/1.14-milliliter Subcutaneous Pen Injector to treat atopic 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 reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.The plan has prior authorization requirements for this drug. These requirements must be met before coverage can be extended. The submitted documentation does not satisfy the plans coverage criteria.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 Aspirin 81-milligram tablet. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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.Drugs prescribed that are available Over-the-Counter (OTC) are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Calcium Acetate 500-milligram Tablet Chewable to treat an 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 reviewed 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.No diagnosis was given for the requested drug. In order to be considered a Part D drug, a diagnosis is required. As such, it could not be determined whether the requested drug was being prescribed for a medically accepted indication. We require a prescriber statement, medical records including history and physical exam, and clarification of inpatient versus outpatient hospital admission. 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 Citalopram Hydrobromide 20-milligram tablet to treat an 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 reviewed 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.No diagnosis was given for the requested drug. In order to be considered a Part D drug, a diagnosis is required. As such, it could not be determined whether the requested drug was being prescribed for a medically accepted indication. We require a prescriber statement, medical records including history and physical exam, and clarification of inpatient versus outpatient hospital admission. 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 Docusate Sodium 100-milligram capsule. The Part D plan denied the request. We received the case to perform an independent and de novo review. To make our decision, we reviewed 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.Drugs prescribed that are available Over-the-Counter (OTC) are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Furosemide 20-milligram tablet to treat an 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 reviewed 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.No diagnosis was given for the requested drug. In order to be considered a Part D drug, a diagnosis is required. As such, it could not be determined whether the requested drug was being prescribed for a medically accepted indication. We require a prescriber statement, medical records including history and physical exam, and clarification of inpatient versus outpatient hospital admission. 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 Gabapentin 300-milligram capsule to treat an 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 reviewed 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.No diagnosis was given for the requested drug. In order to be considered a Part D drug, a diagnosis is required. As such, it could not be determined whether the requested drug was being prescribed for a medically accepted indication. We require a prescriber statement, medical records including history and physical exam, and clarification of inpatient versus outpatient hospital admission. 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 NP Thyroid 30-milligram tablet 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 reviewed 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. According to Medicare sources, the requested drug has not been found by the Food and Drug Administration to be safe and effective; and the drug product label has not been approved. Therefore, the drug is excluded from coverage under Medicare Part D. This decision does not concern 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 Ondansetron 4-milligram tablet to treat an 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 reviewed 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.No diagnosis was given for the requested drug. In order to be considered a Part D drug, a diagnosis is required. As such, it could not be determined whether the requested drug was being prescribed for a medically accepted indication. We require a prescriber statement, medical records including history and physical exam, and clarification of inpatient versus outpatient hospital admission. 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 Oxycodone 5-milligram tablet to treat an 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 reviewed 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.No diagnosis was given for the requested drug. In order to be considered a Part D drug, a diagnosis is required. As such, it could not be determined whether the requested drug was being prescribed for a medically accepted indication. We require a prescriber statement, medical records including history and physical exam, and clarification of inpatient versus outpatient hospital admission. 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 Oxycontin 12-Hour Extended Release 10-milligram Tablet Abuse-Deterrent to treat an 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 reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.No diagnosis was given for the requested drug. In order to be considered a Part D drug, a diagnosis is required. As such, it could not be determined whether the requested drug was being prescribed for a medically accepted indication. We require a prescriber statement, medical records including history and physical exam, and clarification of inpatient versus outpatient hospital admission. 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 Spironolactone 25-milligram tablet to treat an 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 reviewed 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.No diagnosis was given for the requested drug. In order to be considered a Part D drug, a diagnosis is required. As such, it could not be determined whether the requested drug was being prescribed for a medically accepted indication. We require a prescriber statement, medical records including history and physical exam, and clarification of inpatient versus outpatient hospital admission. 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 Acetaminophen 500 milligram prescribed for unknown diagnosis in an oupatient stay. The Part D plan denied the reimbursement request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Allopurinol 300 milligram prescribed for unknown diagnosis in a hospital outpatient stay. The Part D plan denied the reimbursement 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 submitted documentation shows the enrollee received the requested drug 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 including the amount charged for the self-administered drugs and a credit card receipt indicating a total amount paid by the enrollee. However, the enrollees payment amount conflicts with the self administered portion of the bill that indicates multiple credits were applied. The enrollee did not provide clarification. Therefore, reimbursement criteria has not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Amlodipine 5 milligram prescribed for unknown diagnosis in a hospital outpatient stay. The Part D plan denied the reimbursement 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 submitted documentation shows the enrollee received the requested drug 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 including the amount charged for the self-administered drugs and a credit card receipt indicating a total amount paid by the enrollee. However, the enrollees payment amount conflicts with the self administered portion of the bill that indicates multiple credits were applied. The enrollee did not provide clarification. Therefore, reimbursement criteria has not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Atorvastatin 20 milligram prescribed for unknown diagnosis in a hospital outpatient stay. The Part D plan denied the reimbursement 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 submitted documentation shows the enrollee received the requested drug 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 including the amount charged for the self-administered drugs and a credit card receipt indicating a total amount paid by the enrollee. However, the enrollees payment amount conflicts with the self administered portion of the bill that indicates multiple credits were applied. The enrollee did not provide clarification. Therefore, reimbursement criteria has not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Celecoxib 100 milligram prescribed for unknown diagnosis in a hospital outpatient stay. The Part D plan denied the reimbursement 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 submitted documentation shows the enrollee received the requested drug 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 including the amount charged for the self-administered drugs and a credit card receipt indicating a total amount paid by the enrollee. However, the enrollees payment amount conflicts with the self administered portion of the bill that indicates multiple credits were applied. The enrollee did not provide clarification. Therefore, reimbursement criteria has not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Combivent inhaler 1 milligram prescribed for unknown diagnosis in a hospital outpatient stay. The Part D plan denied the reimbursement 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 submitted documentation shows the enrollee received the requested drug 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 including the amount charged for the self-administered drugs and a credit card receipt indicating a total amount paid by the enrollee. However, the enrollees payment amount conflicts with the self administered portion of the bill that indicates multiple credits were applied. The enrollee did not provide clarification. Therefore, reimbursement criteria has not been met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Culturelle 1 milligram prescribed for unknown diagnosis in an oupatient stay. The Part D plan denied the reimbursement request.We received the case to perform an independent and de novo review. To make our decision, we reviewed all documentation submitted, including the case file from the plan, and any information submitted at the reconsideration level.Drugs prescribed that are available Over the Counter are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.