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

At issue is Loteprednol Etabonate 0.5% drops. 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 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 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 Novolin R Relion 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. The record shows the Novolin R Relion was purchased without a prescription. Therefore, the plan is not required to cover or provide reimbursement for the drug.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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Bupropion Extended Release 150 milligram tablet. 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. We asked your prescriber to send us additional information including documentation of why all the lower tier drugs available would be less effective than the requested drug. Your prescriber did not send all of the information required.Bupropion Extended Release 150 milligram tablet is a generic drug on Tier 3 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

You requested Metanx oral capsule prescribed daily for peripheral neuropathy.We requested the case to perform 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.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 the Metanx.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 Lidoderm 5% patch prescribed three patches every 12 hours as needed for chronic 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. 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 (such as Lidocaine patch). 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 Lidoderm 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Itraconazole 100 milligram capsules prescribed for tinea unguium (nail fungal infection). The Part D plan denied the request for coverage.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level. The Part D plan has prior authorization requirements that must be met before coverage of this medication will be approved. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records. 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 Novolin N 35 units 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. The record shows the Novolin N was purchased without a prescription. Therefore, the plan is not required to cover or provide reimbursement for the drug.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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hydroxyzine Hydrochloride 10 milligram tablets to treat anxiety. 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 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 requested documentation.You requested Hydroxyzine Hydrochloride 10 milligram tablets to treat anxiety. DRUGDEX shows anxiety is a medically accepted indication for the requested drug. However, no medical records have been provided to determine if this enrollee has met the criteria for a medically acceptable indication per the approved Medicare compendia.A physician reviewed your appeal and determined that the plan is not required to cover Hydroxyzine Hydrochloride 10 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zioptan 0.0015% solution prescribed daily for primary open-angle glaucoma. 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. Your doctor did not address why all other drugs available on your plans formulary would not work for you.A physician reviewed your appeal and determined that the plan is not required to cover Zioptan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hyalgan 20 milligram per 2 milliliter prefilled syringe prescribed once a week for three weeks for primary osteoarthritis of the left and right knee. 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 Hyalgan because it is considered a medical device, not a prescription drug. Medical devices 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 Azathioprine 50 milligram oral tablet prescribed daily for pulmonary fibrosis and interstitial lung disease. The Part D plan denied your request. We received the case to perform an independent and de novo review. To make our decision, we read 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 Azathioprine to treat your pulmonary fibrosis and interstitial lung disease. 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 condition. 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 Azathioprine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Relion Prime glucose test strips prescribed for the treatment of diabetes.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.We determined that the plan is not required to cover Relion Prime glucose test strips. Supplies for testing and monitoring blood glucose levels are not considered Part D drugs. Although this item is not covered under Part D, it may be covered under Part B. Please submit your request to Medicare Part B. This decision does not address the medical necessity or appropriateness of the testing strips. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue coverage for Tretinoin 0.1% cream prescribed for an unknown condition. The Part D plan denied the request stating that the prior authorization requirements were not met, as the prescriber responded that the enrollee did not have a diagnosis of acne vulgaris.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 does not include a prescriber statement or 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 is not eligible for coverage under Medicare Part D. A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cyclobenzaprine Hydrochloride 10 milligram oral tablet. 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. We asked your prescriber to send us information about 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 similar medications on the lower tiers would not work for you. However, we did not receive the documentation.Cyclobenzaprine Hydrochloride is a generic drug on Tier 3 of the plans formulary. Your doctor did not address why the drugs available on the lower tiers of your plans formulary would not work for you. 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 a formulary exception request for Mesalamine 1000 milligram suppository prescribed for ulcerative colitis. 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 documentation did not include a supporting statement. A request for information was sent to the prescriber; however, no further documentation was received. The documentation submitted did not indicate that all the formulary alternatives were tried and would be ineffective.A physician reviewed your appeal and determined that the plan is not required to cover Mesalamine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Xeljanx XR 11 milligram tablet prescribed for rheumatoid arthritis. 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 Xeljanx XR.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Sirolimus 0.5 milligram tablets prescribed for heart transplant status. 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 also researched Medicare systems and reviewed the enrollment data available.The record shows the enrollee had a heart transplant in May 2019. According to Medicare enrollment records, the enrollee was entitled to Medicare Part A coverage at the time of the transplant. Therefore, the transplant is considered a Medicare covered transplant and is eligible for coverage under Medicare Part B. Medicare Part B covers prescription drugs used in immunosuppressive therapy furnished to an enrollee who has received an organ transplant. Drugs which are eligible for Part B coverage are excluded from Part D coverage by Medicare law.We determined that the Medicare Part D plan is not required to cover Sirolimus. 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. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anoro Ellipta 62.5-25 microgram blisters with device 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. Anoro Ellipta 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 Topamax 25 milligram tablets prescribed to treat bipolar 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 Topamax 25 milligram tablets to treat bipolar 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 Topamax 25 milligram tablets.
Appeal type: Prescription Drug
Decision: Favorable

At issue is a request for coverage of Testosterone Cypionate 200 milligram per milliliter oil for intramuscular injection.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. During this review, a prescriber statement and supporting medical records were requested from the prescriber. The prescriber responded and submitted the requested documentation.The submitted medical records indicate that Testosterone Cypionate has been prescribed for the treatment of hypogonadotropic hypogonadism associated with the presence of Kallmann syndrome. As outlined in the Medicare approved compendia, hypogonadotropic hypogonadism is a medically accepted indication for the use of the requested drug. The Part D plans prior authorization requirements for the coverage of the medication include documentation of primary or secondary hypogonadism in males with multiple symptoms of hypogonadism including at least one of the following specific symptoms: height loss due to vertebral fractures, low trauma fractures, low bone density, incomplete or delayed sexual development, breast discomfort, loss of axillar and/or pubic body hair, or hot flushes. As noted previously, the records indicate that the enrollee has primary hypogonadism/ hypogonadotropic hypogonadism. Additionally, the medical records support the presence of symptoms of hypogonadism including increased breast size, breast discomfort, and low libido. The plans other prior authorization requirement for coverage of the requested medication is documentation of one of the following: a low testosterone level below the normal range for the laboratory; a total testosterone level near the lower limit of the normal range with a low free testosterone level which is less than normal based upon the laboratory reference range; or the enrollee is not producing any testosterone. The submitted laboratory results obtained on May 18, 2021, show that the enrollee has a total testosterone level of 14 nanograms per deciliter and a free testosterone level of 4.0 picograms per milliliter, both of which are significantly below the normal laboratory reference range.Therefore, the submitted documentation supports that the medication is being used for a medically accepted indication and that the plans prior authorization requirements have been met. The plan does not have any additional requirements for coverage of this drug, such as step therapy or quantity limit requirements. Therefore, coverage for the drug can be allowed. A physician reviewed the appeal and determined that the plan is required to cover the Testosterone Cypionate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Humalog 100 international units per milliliter Kwikpen. 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.Humalog Kwikpen is a biological drug on Tier 3 of the plans formulary. There are no biological 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 Metaxalone 800 milligram tablets prescribed as directed for chronic neck 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 the doctor prescribed Metaxalone to treat chronic neck and low back pain. However, the Medicare approved compendia do not support the use of this drug for the enrollees chronic condition. A physician reviewed your appeal and determined that the plan is not required to cover Metaxolone.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Prolia 60 milligrams per milliliter prescribed every six months for age-related osteoporosis without current pathological fracture. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read the case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any records submitted at the reconsideration level. 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 received the documentation and included it in our review.The medical records show the doctor prescribed Prolia to treat the enrollees age-related osteoporosis without current pathological fracture. The 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 the appeal and determined that the plan is not required to cover Prolia. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.