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

At issue is Humira 40-milligrams/0.4-milliliter Pen Injection Kit to treat granuloma annulare. 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 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 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 Xarelto 20 milligram tablet prescribed daily for history of pulmonary embolism. The Part D plan denied the request for a tiering exception.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. Xarelto 20 milligram tablet 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 your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Dupixent 300-milligrams/2-milliliters to treat atopic dermatitis. 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.This medication is not on your plan's list of medications. The prescriber has not given a clear and valid medical reason why all medications required by the plan, on that list, did not work for you. This reason has to be in the medical record with details of when you tried those medications. The reason the medications on the formulary won't work or could cause you harm have to be stated. Why the other medications required by the plan will not work must be discussed. Therefore, an exception to the plans formulary coverage criteria is not supported. A physician reviewed the appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Fentanyl 100 microgram per hour transdermal 72-hour patches prescribed for an unknown condition. The Part D plan denied the request because there was insufficient documentation to determine if the drug was being prescribed for a medically accepted indication.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.Part D plans are responsible for ensuring that a drug is being prescribed for a medically accepted indication. The prescriber has not provided a diagnosis or any supporting medical records. During this review, a request was submitted to the prescriber to provide a diagnosis, to address the plans coverage requirements for this medication, and to provide supporting medical records. The prescriber did not respond to the request. 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 a tiering exception request for Estradiol 10 microgram vaginal tablets prescribed for postmenopausal atrophic vaginitis. 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. Estradiol vaginal tablet is a generic drug on Tier 4 of the plans formulary. The prescriber has not indicated if all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug.  Therefore, this drug is not eligible for a tiering exception.A physician reviewed the appeal and determined that the plan is not required to cover the requested drug at a lower cost tier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Gabapentin 300 milligram capsules prescribed for an unknown condition. 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. Part D plans are responsible for ensuring that a drug is being prescribed for a medically accepted indication. The prescriber has not provided a diagnosis or any supporting medical records. During this review, a request was submitted to the prescriber to provide a diagnosis, to address the plans coverage requirements for this medication, and to provide supporting medical records. The prescriber did not respond to the request. 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 Lidocaine 5% patch for chronic hip pain. 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 documentation shows Lidocaine 5% patch was prescribed to treat chronic hip pain after hip replacement. However, the Medicare approved compendia do not support the use of this drug for the enrollee's condition. A physician reviewed the appeal and determined that the plan is not required to cover Lidocaine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hetlioz 20 milligram capsule to treat non-24-hour sleep-wake 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. We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why the enrollee needs this medication. We did not receive the documentation requested. The documentation shows Hetlioz was prescribed to treat non-24-hour sleep-wake disorder. 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 Hetlioz. 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 request for coverage of MS Contin 60 milligram and 15 milligram tablets prescribed for chronic pain associated with sickle cell thalassemia. 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. This medication is not on your plan's list of medications. The prescriber has not given a clear and valid medical reason why all medications required by the plan, on that list, did not work for you. This reason has to be in the medical record with details of when you tried those medications. The reason the medications on the formulary won't work or could cause you harm have to be stated. Why the other medications required by the plan will not work must be discussed. Therefore, an exception to the plans formulary coverage criteria is not supported. 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 Sunosi 150 milligram tablet prescribed daily for narcolepsy, chronic fatigue, and central sleep apnea. 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 the medication was needed. Specifically, we asked for records to show why other medications on the plan's formulary would not work. We received an incomplete prescriber statement.  The questions that we asked were not answered.The doctor prescribed Sunosi for narcolepsy, chronic fatigue, and central sleep apnea. The Medicare approved compendium support the use of the requested drug. However, 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. A physician reviewed this appeal and determined that the plan is not required to cover Sunosi.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Aspirin 325 milligram tablet. The Part D plan denied the enrollees 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 the enrollee received Aspirin 325 milligram tablet 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 325 milligram tablet is on Medicares excluded list of drugs because it is an over-the-counter medication. Therefore, we determined that the Part D plan is not required to cover or reimburse the enrollee for Aspirin 325 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Magnesium Hydroxide 400 milligram/5 milliliter. The Part D plan denied the enrollees 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 the enrollee received Magnesium Hydroxide 400 milligram/5 milliliter 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. Magnesium Hydroxide 400 milligram/5 milliliter is on Medicares excluded list of drugs because it is an over-the-counter medication. Therefore, we determined that the Part D plan is not required to cover or reimburse the enrollee for Magnesium Hydroxide 400 milligram/5 milliliter.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Sennosides-Docusate Sodium 8.6-50 milligram tablet. The Part D plan denied the enrollees 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 the enrollee received Sennosides-Docusate Sodium 8.6-50 milligram tablet 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. Sennosides-Docusate Sodium 8.6-50 milligram tablet is on Medicares excluded list of drugs because it is an over-the-counter medication. Therefore, we determined that the Part D plan is not required to cover or reimburse the enrollee for Sennosides-Docusate Sodium 8.6-50 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Tylenol 325 milligram tablet. The Part D plan denied the enrollees 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 the enrollee received Tylenol 325 milligram tablet 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. Tylenol 325 milligram tablet is on Medicares excluded list of drugs because it is an over-the-counter medication. Therefore, we determined that the Part D plan is not required to cover or reimburse the enrollee for Tylenol 325 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Tylenol 500 milligram tablet. The Part D plan denied the enrollees 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 the enrollee received Tylenol 500 milligram tablet 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. Tylenol 500 milligram tablet is on Medicares excluded list of drugs because it is an over-the-counter medication. Therefore, we determined that the Part D plan is not required to cover or reimburse the enrollee for Tylenol 500 milligram tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Myrbetriq 50 milligram tablets prescribed for the enrollees condition. The Part D plan denied the request for a tiering exception.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.Myrbetriq 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

The enrollee requested Synthroid 150 microgram tablet. The Part D Plan denied the enrollees 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.Medicare Part D does not cover drugs dispensed from an out-of-network pharmacy. The record shows that the enrollee obtained the Synthroid from an out-of-network pharmacy. Therefore, we determined that the plan is not required to reimburse the enrollee for the 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trintellix 10 milligram tablet. The Part D plan denied the 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. Trintellix 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 the request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Fiasp Flextouch Pen 100u/MI prescribed for unknown diagnosis. The Part D plan denied the enrollees 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 Fiasp Flextouch Pen 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 Fiasp Flextouch Pen. 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 Fiasp Flextouch Pen.
Appeal type: Prescription Drug
Decision: Unfavorable

The enrollee requested Tresiba Flextouch Pen 100u/MI prescribed for unknown diagnosis. The Part D plan denied the enrollees 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 Tresiba Flextouch Pen 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 Tresiba Flextouch Pen. 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 Tresiba Flextouch Pen.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Cosentyx 150 milligram per milliliter subcutaneous injection pens (2 pens to equal 300 milligrams) prescribed for plaque psoriasis.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 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

At issue is Ativan 2-milligram tablet to treat anxiety disorder. 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.This medication is not on your plan's list of medications. The prescriber has not given a clear and valid medical reason why all medications required by the plan, on that list, did not work for you. This reason has to be in the medical record with details of when you tried those medications. The reason the medications on the formulary won't work or could cause you harm have to be stated. Why the other medications required by the plan will not work must be discussed. Therefore, an exception to the plans formulary coverage criteria is not supported. 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 Inderal Long Acting 10-milligram capsule to treat hypertension. 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.This medication is not on your plan's list of medications. The prescriber has not given a clear and valid medical reason why all medications required by the plan, on that list, did not work for you. This reason has to be in the medical record with details of when you tried those medications. The reason the medications on the formulary won't work or could cause you harm have to be stated. Why the other medications required by the plan will not work must be discussed. Therefore, an exception to the plans formulary coverage criteria is not supported. 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 Hyophen 81.6-0.12-milligram tablet to treat interstitial cystitis without hematuria. 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 determined that the plan is not required to cover the Hyophen. According to Medicare rules, Hyophen has not been approved by the Food and Drug Administration. Therefore, the drug is excluded from coverage under Medicare Part D. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit