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

At issue is NP Thyroid 120 milligrams prescribed daily for hypothyroidism.  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.In this case, the requested drug is not approved by the United States Food and Drug Administration. Non-FDA approved drugs are excluded from Medicare Part D coverage.  Per the Medicare approved compendia, This drug has not been found by the United States Food and Drug Administration to be safe and effective, and the drug product labeling has not been approved by the Food and Drug Administration. A physician reviewed your appeal and determined that the plan is not required to cover NP Thyroid.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5% patch prescribed 30 per 2 days for cervical radiculopathy. 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 prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication was needed. We did not receive the documentation requested.The doctor prescribed Lidocaine 5% patch to treat enrollees cervical radiculopathy. However, the Medicare approved compendia do not support the use of this drug for this condition. A physician reviewed this appeal and determined that the plan is not required to cover Lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol HFA 90 microgram inhaler prescribed for an 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 plan reprocessed your claim for the Albuterol HFA inhaler and adjusted the amount owed due to a change in your low income subsidy copayment level. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan adjusted the copayment because according to Medicare records, you did not qualify for low income subsidy copay level. The plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its recalculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of a Levalbuterol HFA 45 microgram per actuation aerosol inhaler prescribed for an unknown condition. The 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. The available documentation did not include any medical records from the prescriber. During this review, a request was submitted to the prescriber to provide a diagnosis and supporting medical records. A reply from the prescriber was not received. Without a diagnosis it cannot be established that the requested drug is being prescribed for a medically accepted indication. As such, the requested drug 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: Unfavorable

At issue is a tiering exception request for Tradjenta 5 milligram tablets 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.Tradjenta 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 your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vemlidy 25 milligram tablets 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. This drug is included on Tier 5 of the plans formulary. This tier is identified as a Specialty Tier. The plan is not required to grant a tiering exception for drugs available on their Specialty Tier. Therefore, a tiering exception cannot be considered.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

At issue is Diclofenac Sodium gel prescribed for an unknown diagnosis. The Part D plan denied the request. We performed an independent and de novo review. To make our decision, we reviewed the appeal carefully. We reviewed all documentation available. We also researched Medicare systems and reviewed the enrollment data available.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication was needed. We did not receive the documentation requested.No medical records were provided by the prescriber to support a diagnosis. Without a diagnosis it cannot be established that the requested drug is being prescribed for a medically accepted indication.  As such, the requested drug does not satisfy the definition of a Medicare Part D drug.  Therefore, the requested drug is not eligible for coverage under Medicare Part D. A physician reviewed this appeal and determined that the plan is not required to cover Diclofenac Sodium gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 1% gel 50 milligrams per 5 grams prescribed two packets per day. 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.Testosterone 1% gel is a generic drug on Tier 3 of the plans formulary. There are no generic 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 Uceris 2 milligram foam prescribed for ulcerative colitis. 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 Uceris to treat your ulcerative colitis. 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 Uceris.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Restasis 0.05 percent ophthalmic drops prescribed twice daily. 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. Restasis 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 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 Forteo solution pen-injector 620 microgram/2.15 milliliter prescribed for osteopenia. 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 Forteo to treat your osteopenia. 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 Forteo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is prescribed Soliris 330 milligram per 30 milliliter vial for myasthenia gravis. 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 Soliris to treat your myasthenia gravis. 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 Soliris. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a prior authorization request for Otezla 30 milligram tablets prescribed for psoriasis vulgaris. The Part D plan denied coverage.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 records submitted at the reconsideration level. The documentation does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed the plans coverage criteria and has not indicated why all alternatives required by the plan, with supporting medical documentation, would likely cause harm or not be as effective as the requested drug. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Invokana 300 milligram tablet prescribed for an unknown diagnosis. 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 plan denied your request for a tier exception because there is no brand name drug in a lower cost-sharing tier. However, the record shows the plan reprocessed a claim for the Invokana and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply deductible, coinsurance, and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, your deductible of $445 had not been met at the time of purchase. The plan shows you paid $141 as a copay. However, the total amount approved as your cost share was $576. Therefore, the plan recalculated and your share of the cost $435 was applied to your deductible. We have determined that the plan is correct in its calculation of the owed amount towards your deductible.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xiidra 5% solution prescribed to treat dry eye syndrome. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.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 your appeal and determined that the plan is not required to cover Xiidra 5% solution.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Engerix-B 20 microgram/milliliter syringe prescribed for hepatitis vaccination. 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 information provided to the plan places you in a high risk category for hepatitis B. Medicare rules state Medicare Part B pays for hepatitis B vaccine if you are at an intermediate or high risk for contracting hepititis B. Therefore, we determined that the plan is not required to cover the Engerix-B. The plan indicates the Engerix-B is covered under Part B. Please submit your request to Medicare Part B. 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 Myrbetriq ER 50 milligram tablets 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.Myrbetriq ER 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 Repatha Sureclick 140 milligram per milliliter. 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 Repatha to treat hyperlipidemia in an enrollee with essential hypertension, diabetes, and obesity without established atherosclerotic cardiovascular disease. The use of the requested drug to treat the provided diagnoses 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 these conditions. Therefore, the requested drug, as ordered, is not being used for a medically accepted indication. 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 Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Quinine Sulfate 324 milligram capsules prescribed as directed for sleep related leg cramps and low back pain. 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 Quinine Sulfate to treat your sleep related leg cramps and low back pain. 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 Quinine Sulfate.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ondansetron 8 milligram oral tablet prescribed nausea and vomiting. 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 Ondansetron to treat unspecified nausea and vomiting, cause unknown. 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 Ondansetron.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azelex 20% prescribed daily for acne vulgaris. 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 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 Azelex.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Entresto 97-103 milligram tablets. 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. Entresto 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. If there are no brand 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 Entresto at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vitamin D (Ergocalciferol) 1.25 milligram(50000 UT) capsule prescribed for unknown diagnosis. 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, drugs that fall into the category of vitamins and minerals are excluded from coverage under Part D. Therefore, we determined that the plan is not required to cover Vitamin D Ergocalciferol. This decision does not address 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 Rasagiline Mesylate 1 milligram tablet prescribed for Parkinsons disease. 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. Rasagiline Mesylate is a generic drug on Tier 4 of the plans formulary. The medical records do not support that all drugs available on lower tiers to treat your condition have been tried or deemed contraindicated. 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

At issue is Tirosint 50 microgram oral capsule prescribed daily for primary hypothyroidism. 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. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all formulary alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. A physician reviewed your appeal and determined that the plan is not required to cover Tirosint.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patches. 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.The submitted documentation did not include medical records or a supporting statement. A request for information was sent to your physician. Medical records and a supporting statement were not received. Therefore, as it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.