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

The enrollee requested Aspirin EC 325 milligram tablet 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.The record shows the enrollee received Aspirin 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. Aspirin is on Medicares excluded list of drugs because it does not meet the definition of a Part D drug. In addition, the plans Evidence of Coverage indicates that the supplemental benefit permits coverage for certain approved over-the-counter drugs/products, but only when ordered online by mail order. Therefore, we determined that the Part D plan is not required to cover Aspirin or provide reimbursement to the enrollee.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Celecoxib 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 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. A receipt was provided. However, there was no reimbursement request form in the record. In addition, the enrollee nor the plan provided enough medical records (history and physical, admission record, medical administration record, and discharge summary) to determine if these drugs would have been covered under the Medical benefit (Medicare Advantage Plan) or Part D, or what type of admission the enrollee underwent. Therefore, we determined that reimbursement cannot be allowed at this time based on insufficient documentation submitted.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Cholecalciferol 5000 unit capsule 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.The record shows the enrollee received Cholecalciferol 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. Cholecalciferol is on Medicares excluded list of drugs because it does not meet the definition of a Part D drug. In addition, the plans Evidence of Coverage indicates that the supplemental benefit permits coverage for certain approved over-the-counter drugs/products, but only when ordered online by mail order. Therefore, we determined that the Part D plan is not required to cover Cholecalciferol or provide reimbursement to the enrollee.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Citric Acid Sodium Citrate 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.The record shows the enrollee received Citric Acid Sodium Citrate 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. Citric Acid Sodium Citrate is on Medicares excluded list of drugs because it does not meet the definition of a Part D drug. In addition, the plans Evidence of Coverage indicates that the supplemental benefit permits coverage for certain approved over-the-counter drugs/products, but only when ordered online by mail order. Therefore, we determined that the Part D plan is not required to cover Citric Acid Sodium Citrate or provide reimbursement to the enrollee.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Famotidine 20 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 received Famotidine 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. A receipt was provided. However, there was no reimbursement request form in the record. In addition, the enrollee nor the plan provided enough medical records (history and physical, admission record, medical administration record, and discharge summary) to determine if these drugs would have been covered under the Medical benefit (Medicare Advantage Plan) or Part D, or what type of admission the enrollee underwent. Therefore, we determined that reimbursement cannot be allowed at this time based on insufficient documentation submitted.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Hydrocodone 325-5 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 received Hydrocodone 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. A receipt was provided. However, there was no reimbursement request form in the record. In addition, the enrollee nor the plan provided enough medical records (history and physical, admission record, medical administration record, and discharge summary) to determine if these drugs would have been covered under the Medical benefit (Medicare Advantage Plan) or Part D, or what type of admission the enrollee underwent. Therefore, we determined that reimbursement cannot be allowed at this time based on insufficient documentation submitted.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested multivitamin with minerals 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.The record shows the enrollee received multivitamin with minerals 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. multivitamin with minerals is on Medicares excluded list of drugs because it does not meet the definition of a Part D drug. In addition, the plans Evidence of Coverage indicates that the supplemental benefit permits coverage for certain approved over-the-counter drugs/products, but only when ordered online by mail order. Therefore, we determined that the Part D plan is not required to cover multivitamin with minerals or provide reimbursement to the enrollee.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Oxycodone 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 received Oxycodone 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. A receipt was provided. However, there was no reimbursement request form in the record. In addition, the enrollee nor the plan provided enough medical records (history and physical, admission record, medical administration record, and discharge summary) to determine if these drugs would have been covered under the Medical benefit (Medicare Advantage Plan) or Part D, or what type of admission the enrollee underwent. Therefore, we determined that reimbursement cannot be allowed at this time based on insufficient documentation submitted.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Oxycontin CR 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 received Oxycontin CR 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. A receipt was provided. However, there was no reimbursement request form in the record. In addition, the enrollee nor the plan provided enough medical records (history and physical, admission record, medical administration record, and discharge summary) to determine if these drugs would have been covered under the Medical benefit (Medicare Advantage Plan) or Part D, or what type of admission the enrollee underwent. Therefore, we determined that reimbursement cannot be allowed at this time based on insufficient documentation submitted.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Pantoprazole 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 received Pantoprazole 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. A receipt was provided. However, there was no reimbursement request form in the record. In addition, the enrollee nor the plan provided enough medical records (history and physical, admission record, medical administration record, and discharge summary) to determine if these drugs would have been covered under the Medical benefit (Medicare Advantage Plan) or Part D, or what type of admission the enrollee underwent. Therefore, we determined that reimbursement cannot be allowed at this time based on insufficient documentation submitted.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Pregbalin 50 milligram capsule 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 received Pregbalin 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. A receipt was provided. However, there was no reimbursement request form in the record. In addition, the enrollee nor the plan provided enough medical records (history and physical, admission record, medical administration record, and discharge summary) to determine if these drugs would have been covered under the Medical benefit (Medicare Advantage Plan) or Part D, or what type of admission the enrollee underwent. Therefore, we determined that reimbursement cannot be allowed at this time based on insufficient documentation submitted.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Senna 8.6 milligram tablet 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.The record shows the enrollee received Senna 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. Senna is on Medicares excluded list of drugs because it does not meet the definition of a Part D drug. In addition, the plans Evidence of Coverage indicates that the supplemental benefit permits coverage for certain approved over-the-counter drugs/products, but only when ordered online by mail order. Therefore, we determined that the Part D plan is not required to cover Senna or provide reimbursement to the enrollee.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tadalafil 10 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 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 medical records support that Tadalafil is prescribed for erectile dysfunction. Drugs used to treat sexual or erectile dysfunction are excluded from Medicare Part D drug benefits. A physician reviewed your appeal and determined that the plan is not required to cover Tadalafil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Entresto 49-51 milligram tablets prescribed to take 1 tablet, by mouth, twice daily to treat congestive heart failure. The Part D plan denied the tiering exception request.The QIC 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.Entresto 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

At issue is Cyclobenzaprine Hydrochloride 5 milligram tablets prescribed for low back pain. 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 Cyclobenzaprine Hydrochloride for low back pain. 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.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 Fasenra 30 milligram/milliliter injection was prescribed for severe persistent asthma. The Part D plan denied the request because the drug was not listed on the plans formulary. 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 show Fasenra was prescribed to treat severe persistent asthma. However, the prescriber has not indicated why all formulary alternatives required by the Plan would not be as effective as the requested drug for the enrollee, and/or would likely cause adverse reaction(s) or other harm to the enrollee. Therefore, a formulary exception will not be considered.A physician reviewed your appeal and determined that the plan is not required to cover Fasenra.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dextroamphetamine-Amphetamine Extended Release 15-milligram capsule. At initial determination and redetermination the diagnosis of narcolepsy was given. 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.At reconsideration a diagnosis of attention-deficit hyperactivity disorder, predominantly inattentive type was given. 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 requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine Patch 5% prescribed for a traumatic injury of knee without tenderness or effusion. 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 medical records support Lidocaine Patch 5% is prescribed for traumatic injury of knee without tenderness or effusion. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed your appeal and determined that the plan is not required to cover Lidocaine Patch 5%.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dronabinol 5 milligram capsules prescribed for nausea and vomiting associated with heartburn/reflux and dysphagia. 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 Dronabinol for nausea and vomiting associated with heartburn/reflux and dysphagia. 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.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested prior authorization for Modafinil 200 milligram tablets prescribed as directed for attention deficit hyperactivity disorder. 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 your doctor prescribed Modafinil to treat your attention deficit hyperactivity disorder. 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 Modafinil.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dronabinol 2.5 milligram capsules prescribed for nausea in an enrollee with nutritional deficiency. 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 Dronabinol for nausea in an enrollee with nutritional deficiency. The enrollee is also noted to have been diagnosed with colitis, enterococcal urinary tract infection, percutaneous endoscopic gastrostomy tube dislodgment with sepsis, and generalized anxiety disorder. 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.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 Lidocaine 5% patches prescribed for back pain subsequent to a thoracic-12 compression fracture. 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 Lidocaine 5% patches for back pain subsequent to a thoracic-12 compression fracture. 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.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 a request for coverage of Calcipotriene 0.005% / Clobetasol Propionate 0.05% solution prescribed for the treatment of seborrheic dermatitis.  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.Calcipotriene 0.005% / Clobetasol Propionate 0.05% solution has not has not been found by the Food and Drug Administration to be safe and effective and has not been approved by the Food and Drug Administration. Drugs not approved by the Food and Drug Administration are excluded from Part D coverage. We have determined that the Medicare Part D plan is not required to cover the requested drug. 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.