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

At issue is Droxidopa 300 milligram capsule prescribed for symptomatic neurogenic orthostatic hypotension. 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. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The enrollee has not satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Droxidopa. 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 Wegovy 2.4 milligram/0.75 milliliter injection prescribed for diabetes and obesity. 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.We determined that the plan is not required to cover Wegovy because it was prescribed for obesity. Drugs to treat anorexia, weight loss, or weight gain are excluded from coverage. The plan does not offer supplemental (additional) coverage for this drug. If the enrollee purchased drugs that are excluded, the enrollee must pay for them. 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 Vraylar 1.5 milligram capsule prescribed for bipolar disorder, dysthymic disorder, persistent mood affective disorder, unspecified and insomnia. 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. We requested additional information from the prescriber to confirm a diagnosis and for information on other treatments tried but did not get a response. In order to establish medical necessity and confirm that the requested drug is being used for a medically accepted indication, as required by Medicare, documentation supporting a medically accepted indication are required. The information was insufficient to determine medical necessity and if the drug is eligible for coverage under Part D benefits. A physician reviewed your appeal and determined that the plan is not required to cover Vraylar.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Methocarbamol 500-milligram tablet to treat chronic pain syndrome. 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.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 Botox 100 unit vial prescribed for unknown diagnosis. 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 record shows the Botox was dispensed from a preferred pharmacy for an amount that is less than or equal to the required copayment/coinsurance amount. The plans Evidence of Coverage indicates 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. The plan paid its share of the cost for the covered drug and you were responsible for the copay. We determined your copay for Botox was correctly calculated and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone Cypionate 200 milligram/milliliter prescribed for decreased libido. 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. The prescriber indicates Testosterone Cypionate 200 milligram/milliliter is prescribed to treat decreased libido. However, 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 Testosterone Cypionate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Bupropion Hydrochloride 75 milligram powder for date of service July 19, 2021, to treat the enrollees condition. The Part D plan denied the appeal 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.The record shows the Bupropion Hydrochloride 75 milligram powder was to used as a compounded drug. Medicare Part D. does not cover compounded drugs. In addition, Bupropion Hydrochloride 75 milligram powder has a National Drug Codes that is not listed with the Food and Drug Administration as a valid code. Therefore, this drug is not eligible for coverage under Medicare Part D.Therefore, we determined the plan is not required to cover and/or reimburse Bupropion Hydrochloride 75 milligram powder for the date of service July 19, 2021. 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 Gabapentin 150 milligram powder for date of service July 19, 2021, to treat the enrollees condition. The Part D plan denied the appeal 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.The record shows the Gabapentin 150 milligram powder was to be used as a compounded drug. Medicare Part D. does not cover compounded drugs. In addition, Gabapentin 150 milligram powder has a National Drug Codes that is not listed with the Food and Drug Administration as a valid code. Therefore, this drug is not eligible for coverage under Medicare Part D.Therefore, we determined the plan is not required to cover and/or reimburse Gabapentin 150 milligram powder for the date of service July 19, 2021. 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 Hydroxychloroquine Sulfate 200 milligram powder for date of service July 19, 2021, to treat the enrollees condition. The Part D plan denied the appeal 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. The record shows the Hydroxychloroquine Sulfate 200 milligram powder is a compounded drug. Medicare Part D. does not cover compounded drugs. In addition, Hydroxychloroquine Sulfate 200 milligram powder has a National Drug Codes that is not listed with the Food and Drug Administration as a valid code. Therefore, this drug is not eligible for coverage under Medicare Part D.Therefore, we determined the plan is not required to cover and/or reimburse Hydroxychloroquine Sulfate 200 milligram powder for the date of service July 19, 2021. 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 Methotrexate 2.5 milligrams for date of service July 19, 2021, to treat the enrollees condition. The Part D plan denied the appeal 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.The record shows the Methotrexate 2.5 milligrams was to be used as a compounded drug. Medicare Part D. does not cover compounded drugs. In addition, Hydroxychloroquine 200 milligram powder sulfate has a National Drug Codes that is not listed with the Food and Drug Administration as a valid code. Therefore, this drug is not eligible for coverage under Medicare Part D.Therefore, we determined the plan is not required to cover and/or reimburse Methotrexate 2.5 milligrams for the date of service July 19, 2021. 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 Uribel 118 milligram capsules to treat the enrollee with interstitial cystitis. The Part D plan denied the appeal 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.The record shows the physician prescribed Uribel 118 milligram capsules. However, the requested drug has not been approved by the United States Food and Drug Administration. Non-Food and Drug Administration approved drugs are excluded from Medicare Part D coverage. Therefore, the requested drug is excluded from coverage. 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 Ipratropium-Albuterol 0.5-3 milligram/milliliter ampule prescribed for the treatment of chronic obstructive pulmonary disease. The Part D plan denied the enrollees request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows the Ipratropium-Albuterol is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover the Ipratropium-Albuterol. Please consider submitting this request to Medicare Part B. 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 Mycophenolate 500 milligram tablet prescribed for lichen planopilaris. 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 prescriber indicates Mycophenolate 500 milligram tablet is prescribed to treat alopecia most consistent with lichen planopilaris. However, 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 Mycophenolate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Zolpidem Tartrate 5 milligram tablets prescribed to treat the enrollee with insomnia. The Part D plan denied the appeal 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.The documentation shows the doctor prescribed Zolpidem Tartrate 5 milligram tablets to treat insomnia. The enrollees 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 Zolpidem Tartrate 5 milligram tablets as the plans prior authorization criteria has not been met. 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 Diclofenac Epolamine 1.3% patch prescribed for ankle pain due to sprains. 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 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 prescriber does not indicate why all of the other alternatives on the plans formulary would not work.A physician reviewed your appeal and determined that the plan is not required to cover Diclofenac Epolamine 1.3% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Latuda 40 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. This drug is included on Tier 4 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 Tobramycin 300 milligram/5milliliter solution prescribed for the treatment of chronic respiratory failure. The Part D plan denied the enrollees request.We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows the Tobramycin is being administered through a nebulizer in the home setting. Medicare Part B may pay for supplies necessary for the effective use of durable medical equipment, including drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic benefit of the durable medical equipment. We determined that the Part D plan is not required to cover the Tobramycin. Please consider submitting this request to Medicare Part B. 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 Shingrix 50 micrograms per 0.5 milliliters vial kit. The Part D plan denied the appeal 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.Shingrix is a biological drug on Tier 4 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 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 Nuedexta 20/10 milligram capsule prescribed for pseudobulbar affect. 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 requested additional information from the prescriber. The information received does not support all prior authorization requirements were met. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The enrollee has not satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Nuedexta. 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 Hetlioz 20 milligram capsule prescribed for circadian rhythm sleep disorder, free running type. 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. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The enrollee has not satisfied the plan's coverage criteria.  A physician reviewed your 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 Metaxalone 800 milligram tablets prescribed for an unknown condition. The case was auto-forwarded by the plan.  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. Metaxalone is not included in the plans formulary. The documentation does not include any medical records from the prescriber. A request was submitted to the prescriber to provide a diagnosis and supporting medical records and to address the alternative medications included in the plans formulary to treat the enrollees condition. 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 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 prior authorization request for Hetlioz 20 milligram capsules prescribed for non-24 hour sleep/wake disorder and total blindness. The Part D plan denied coverage.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 records submitted at the reconsideration level. The submitted documentation does not indicate that the enrollee satisfies the plan's prior authorization coverage criteria.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 tiering exception request for Creon DR 12,000-38,000-60,000 unit delayed release capsules. 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. Creon DR is a biologic drug on Tier 3 of the plans formulary. There are no biologic drugs of the same type on the lower cost sharing tiers. If there are no biologic drugs of the same type on a lower tier, the 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 level. The drug will continue to be covered at the Tier 3 copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synthroid 88 microgram 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. Synthroid is a brand drug on Tier 3 of the plans formulary. Your doctor did not address why all 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: Favorable

At issue is a request for coverage of Vraylar 1.5 milligram capsules prescribed for the treatment of bipolar 1 disorder, mixed, severe. 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 plan has prior authorization requirements that must be met before coverage of this medication will be approved. The submitted medical records confirm that the plans coverage requirements have been satisfied. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.