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

At issue is Diphenhydramine Hydrochloride 12.5 milligram/5-milliliter elixir  prescribed for the enrollees condition. 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 determined that the plan is not required to cover Diphenhydramine Hydrochloride. Medicare does not allow Part D drug plans to cover drugs produced by a manufacturer that does not participate in the Medicare Coverage Gap Program. The Centers for Medicare & Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. Records show that the manufacturer, Major Pharmaceuticals, did not sign the agreement and does not participate in the Medicare Gap Discount Program. Therefore, the Part D plan is not required to cover Diphenhydramine Hydrochloride 12.5 milligram/5-milliliter elixir.  The decision does not address medical necessity of the drug. It only indicates that reimbursement cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Tamsulosin 0.4-milligram capsules prescribed as directed. The Part D plan denied your request for a tiering exception.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. Tamsulosin is a brand drug on Tier 2 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 your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Oracit Solution 640-490 milligram. The Part D plan denied your request. We performed and independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We determined that the plan is not required to cover Oracit Solution because it it is a prescription vitamin and mineral product. Drugs prescribed for prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations 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

You requested Diazapam 6 milligram tablets. The record shows the RxSaver discount was applied to the purchase of Diazapam. According to the RxSaver website (https://goodrx.com), the discount coupons are intended for out-of-pocket paying consumers and may not be used with commercial health plans or any federal or state funded health care program, such as Medicare or Medicaid. When you decided to use the RxSaver discount, you acknowledged and agreed that RxSaver will be treated as the primary payor with respect to the medications that you have selected to purchase through the RxSaver discount program. Therefore, the Plan is not required to cover or provide reimbursement for Diazapam. To pursue payment, please update your insurance information at the pharmacy where you purchased these drugs and ask to reprocess the claim through your Part D insurance without applying the RxSaver discount.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hydrocodone-Acetaminophen 5/325 milligram tablet. The record shows the RxSaver discount was applied to the purchase of Hydrocodone-Acetaminophen. According to the RxSaver website (https://goodrx.com), the discount coupons are intended for out-of-pocket paying consumers and may not be used with commercial health plans or any federal or state funded health care program, such as Medicare or Medicaid. When you decided to use the RxSaver discount, you acknowledged and agreed that RxSaver will be treated as the primary payor with respect to the medications that you have selected to purchase through the RxSaver discount program. Therefore, the Plan is not required to cover or provide reimbursement for Hydrocodone-Acetaminophen.To pursue payment, please update your insurance information at the pharmacy where you purchased these drugs and ask to reprocess the claim through your Part D insurance without applying the RxSaver discount.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Corlanor 5 milligram tablet prescribed for inappropriate sinus node tachycardia. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The records show you prescribed Corlanor 5 milligram tablet to treat the enrollees inappropriate sinus node tachycardia. 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 Corlanor 5 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vitamin B12 1000 microgram sublingual tablets prescribed for vitamin deficiency. The Part D plan denied your request. We performed 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 Vitamin B12 because it is a prescription vitamin product. Drugs prescribed for prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations 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

You requested Diclofenac Sodium 1% gel prescribed for chronic pain. The Part D plan denied your request. We performed 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 Diclofenac Sodium 1% gel because it is available over-the-counter. Nonprescription or over-the-counter drugs 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 Ketorolac 10-milligram tablet, 60 tablets per 30 days, to treat 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 plan limits the amount of Ketorolac 10-milligram tablet to 20 tablets per 30 days. The prescriber has not indicated that the number of doses of the requested drug allowed by the plan would likely be ineffective in treating the condition or would be likely to cause harm. The following citation in Drugdex, a Medicare approved compendium, does not support the use of the requested quantity for the enrollee's condition: 'Maximum dosage: 40 mg orally daily. Maximum duration: Alone or sequentially with other formulations (injection and oral) is 5 days.' Therefore, an exception to the plans coverage criteria is not supported. Our physician reviewer's opinion is that quantity limit criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Boostrix vaccine. The Part D plan denied your request for additional reimbursement. We received a 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 submitted documentation that shows you were in the initial coverage stage for part of the cost for this drug and entered the coverage gap stage for the remaining amount. According to your plans Evidence of Coverage, 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 you while you are in the initial coverage stage. During the coverage gap stage you pay 25% of the price for brand name drugs and a portion of the dispensing fee. The record shows the plan paid its share of the cost for the Boostrix, and your cost share was calculated based on a portion of copay in the initial coverage stage and 25% of the coverage gap discount for the remaining amount. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lotemax 0.5 percent suspension prescribed as directed for dry eye syndrome of lacrimal glands. 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 Lotemax 0.5 percent suspension to treat your dry eye syndrome of lacrimal glands. However, the Medicare approved compendia do not support the use of this drug, as prescribed, for your condition. A physician reviewed your appeal and determined that the plan is not required to cover Lotemax 0.5 percent suspension.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Cyclosporine 50 milligram capsules prescribed for an unknown condition for the date of service of January 5, 2021.  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.While we received the required documentation for claim reimbursement, there was no indication in the file as to why you were prescribed this medication. During this review, a request was submitted to your doctor to provide a diagnosis and to provide supporting medical records. Your doctor did not respond to the request. Before coverage and/or reimbursement will be allowed for a drug, it has to be established that the drug is being prescribed for a medically accepted indication. Without a diagnosis, the medical necessity for the drug cannot be determined. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. Therefore, 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 reimburse the amount paid for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Methocarbamol 50 milligram tablets prescribed for an unknown condition for the date of service of January 21, 2021.  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.While we received the required documentation for claim reimbursement, there was no indication in the file as to why you were prescribed this medication. During this review, a request was submitted to your doctor to provide a diagnosis and to provide supporting medical records. Your doctor did not respond to the request. Before coverage and/or reimbursement will be allowed for a drug, it has to be established that the drug is being prescribed for a medically accepted indication. Without a diagnosis, the medical necessity for the drug cannot be determined. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. Therefore, 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 reimburse the amount paid for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Methocarbamol 500 milligram tablets prescribed for an unknown condition for the dates of service of January 6, 2021; January 15, 2021; January 25, 2021; and February 23, 2021.  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.While we received the required documentation for claim reimbursement, there was no indication in the file as to why you were prescribed this medication. During this review, a request was submitted to your doctor to provide a diagnosis and to provide supporting medical records. Your doctor did not respond to the request. Before coverage and/or reimbursement will be allowed for a drug, it has to be established that the drug is being prescribed for a medically accepted indication. Without a diagnosis, the medical necessity for the drug cannot be determined. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. Therefore, 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 reimburse the amount paid for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Morphine Sulfate Immediate Release 15 milligram tablets prescribed for an unknown condition for the date of service of January 25, 2021.  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.While we received the required documentation for claim reimbursement, there was no indication in the file as to why you were prescribed this medication. During this review, a request was submitted to your doctor to provide a diagnosis and to provide supporting medical records. Your doctor did not respond to the request. Before coverage and/or reimbursement will be allowed for a drug, it has to be established that the drug is being prescribed for a medically accepted indication. Without a diagnosis, the medical necessity for the drug cannot be determined. As such, the requested drug does not satisfy the definition of a Medicare Part D drug. Therefore, 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 reimburse the amount paid for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Rytary 61.25/245 milligram capsules prescribed for the enrollees condition. The Part D plan denied your request. We performed 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.Rytary is a brand drug on Tier 4 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 your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Eliquis 5 milligram tablet prescribed for atrial fibrillation. 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 record shows you purchased Eliquis from a network pharmacy for an amount that is less than or equal to the required coinsurance and copayment amount. We reviewed the plans formulary and Evidence of Coverage. In this case, the documentation shows you were in the coverage gap stage when you purchased the Eliquis. The plan paid its share of the cost for the covered drug and you were responsible for your share of the remaining 25%. We determined that the plan is not required to provide additional reimbursement for the Eliquis.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Clonazepam 0.5 milligram 180 oral tablets prescribed twice daily for essential tremors. 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 amount of the medication. We did not receive the documentation requested.Your medical records show your doctor prescribed Clonazepam to treat essential tremor. However, your medical records do not support why an exception to the plans quantity limit is medically necessary. A physician reviewed your appeal and determined that the plan is not required to cover the Clonazepam, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for a tiering exception for Repatha SureClick 140 milligrams per milliliter subcutaneous injection pen prescribed for 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 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.Repatha is a biologic drug on Tier 3 of the plans formulary. There are no biologic drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to cover the Repatha SureClick at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Repatha SureClick 140 milligram/milliliter autoinjector pen prescribed as directed for other hyperlipidemia and atherosclerotic heart disease of native coronary artery without angina pectoris. 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. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Xiidra 5% ophthalmic solution prescribed for keratoconjunctivitis sicca. 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.Xiidra is not included in the plans formulary. The prescriber has not sufficiently addressed why the alternative medications that are included in the plans formulary to treat the noted 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

You requested Gleostine 100 milligram oral capsule prescribed for secondary glioblastoma. 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. According to Medicare rules, Part D drug plans do not cover drugs produced by a manufacturer who does not participate in the Medicare Gap Discount Program. The Center for Medicare and Medicaid Services publishes a list of participating brand name drug manufacturers that have signed the Medicare Coverage Gap Discount Agreement. According to the list, the manufacturer, Wellcare Wellness Rx (PDP), did not sign the agreement and does not participate in the Medicare Gap Discount Program. Therefore, we determined that the plan is not required to cover the Gleostine. The decision does not address medical necessity of the drug. It only indicates that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hysept 0.25% Solution. The Part D plan denied the request. We received a reconsideration 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.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.A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.