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

At issue is Vascepa 1 gram oral capsule. 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.At initial determination the diagnosis of elevated triglycerides with associated coronary artery disease, dyslipidemia, and high blood pressure was given. However, no medical records have been submitted for review. Therefore, it cannot be determined if the requested drug was prescribed for a medically accepted indication supported by the Medicare approved compendia. As such, the formulary exception was not addressed because 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 Vascepa.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Acetylcysteine 20% vial compounded drug prescribed for the treatment of acute on chronic graft-versus-host 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 record shows the Acetylcysteine 20% vial is a compounded drug and each ingredient is reviewed individually. The quantity of the each drug and the National Drug Codes have been provided.The Natures Tears is an over-the-counter drug  and not eligible for coverage under Part D. The Droptainers Ophthalmic 15 milliliter does not meet the definition of a Part D drug and therefore, not eligible for coverage.The National Drug Code provided for Acetylcysteine 20% vial is not listed with the Food and Drug Aministration as a valid code. Therefore, we determined the plan is not required to cover the compounded drug. 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 Polyethylene Glycol 3350 powder prescribed for constipation due to Nelson syndrome. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We determined that the plan is not required to cover Polyethylene Glycol powder because it is an over-the-counter drug. Nonprescription or over-the-counter drugs are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trenfya Injector 100 milligram/milliliter prescribed for psoriasis vulgaris. 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. Your prescriber indicates they prescribed Trenfya Injector 100 milligram/milliliter to treat psoriasis vulgaris. 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. Your prescriber does not state why all 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 Trenfya Injector.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Duexis 800-26.6 milligram oral tablet prescribed twice daily for unilateral primary osteoarthritis of the left knee. 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 Duexis.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Shingrix 50-0.5 milliliter injection prescribed for shingles 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 you were administered the Shingrix vaccine at your physicians office. According to your plan's Evidence of Coverage, reimbursement is based on the total cost of the drug, minus your required co-payment amount, and the difference between what the plan normally pays for the drug and what the out-of-network pharmacy or provider charged you. If you pay the full cost of a prescription, then you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that you paid for the drug was not provided. Therefore, we determined that the plan is not required to reimburse you without the required documentation.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Saxenda 18 milligram/3 milliliter pen injector for morbid obesity due to excess calories. The Part D plan denied your request.We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.We determined that the plan is not required to cover Saxenda because it was prescribed for weight loss. Drugs to treat anorexia, weight loss, or weight gain are excluded from coverage. Your plan does not offer supplemental (additional) coverage for this drug. If you purchased drugs that are excluded, you must pay for them yourself. This decision does not address the medical necessity or appropriateness of the drug. It only establishes that payment cannot be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Novolog 100 units/milliliter vial 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. Novolog 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 Gabapentin 600 milligram tablets prescribed for post laminectomy syndrome and other 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 this medication. The documentation shows your doctor prescribed Gabapentin to treat your post laminectomy syndrome and other chronic 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 Gabapentin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Oxycodone 15 milligram tablet prescribed for unknown diagnosis. 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 you requested reimbursement for Oxycodone that was refilled at your pharmacy prior to the next refill date allowed by your Medicare Part D plan. The plan submitted documentation indicating that you were charged full price for the drug. According to your plan's Evidence of Coverage, if you pay the full cost of a prescription, you may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. In this case, proof of payment in the form of a receipt showing the amount that you paid for the drug was not provided. Therefore, we determined that the plan is not required to reimburse you.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is prescribed Evenity 105 milligram per 1.17 milliliter syringe. 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 received the documentation and included it in our review.Your medical records show your doctor prescribed Evenity to treat your osteoporosis with a history of fragility fractures. 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 Evenity. 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: Favorable

At issue is prescribed Xeljanz 11 milligram extended-release oral tablet. 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 received the documentation and included it in our review.Your medical records show your doctor prescribed Xeljanz to treat your rheumatoid arthritis involving multiple sites with positive rheumatoid factor. Your medical records also show you had an inadequate response to Methotrexate. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The documentation provided shows the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is required to cover Xeljanz. The physician reviewer also determined that an exception to the plans prior authorization requirements can be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Vyndamax 61 milligram capsules prescribed to treat cardiac amyloid transthyretin amyloidosis.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 a prescribers statement, completion of the prior authorization, and medical records or other documentation to show why you need this medication.Your medical records show your doctor prescribed Vyndamax 61 milligram capsules to treat cardiac amyloid transthyretin amyloidosis. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The prescriber completed the initial prior authorization for the requested drug. However, there were no clinical medical records submitted to support the diagnosis and/or laboratory, pathology, and diagnostic results. The documentation provided does not satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to cover Vyndamax 61 milligram capsules, as there were no supporting medical records to justify prior authorization criteria. 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 Exemestane 25 milligram tablet prescribed 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. 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. . We received the documentation and included it in our review.Exemestane is a brand drug on Tier 3 of the plans formulary. The medical records provided substantiated a medically accepted indication. However, your doctor did not establish that 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 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 Diclofenac Epolamine 1.3% patch prescribed for chronic neck and 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. 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. The documentation shows your doctor prescribed Diclofenac Epolamine 1.3% patch to treat your chronic neck and 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 Diclofenac Epolamine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Farxiga 10 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 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 teirs would not work for you. However, we did not receive the documentation.. Farxiga is a brand drug on Tier 4 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.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Nexletol 180 milligram oral tablet prescribed 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. 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. We received the documentation and included it in our review.Nexletol is a brand 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Gabapentin 100 milligram capsule prescribed for polyneuropathy. 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 this medication. We did not receive the documentation requested. The documentation shows your doctor prescribed Gabapentin to treat your polyneuropathy. 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 Gabapentin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Austedo 12 milligram oral tablet. 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. The prescriber returned the request for information form, however no medical records were provided.  Our request specifically stated, 'Medical records MUST be provided.'At initial determination and at redetermination the diagnosis of tardive dyskinesia was given. However, no medical records have been submitted for review. Therefore, it cannot be determined if the requested drug was prescribed for a medically accepted indication. As such, the off-formulary exception was not addressed because 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 Austedo.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Farxiga 10 milligram tablet prescribed for chronic systolic congestive heart failure. 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. 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, medical records were not received to 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 Farxiga.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone 1.62% gel to treat testicular hypofunction. 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.A request was submitted to the prescriber to clarify the medical history and diagnosis, to address the prior authorization criteria, and to provide supporting medical records.  A reply from the prescriber was not received.  The use of the Testosterone 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 Testosterone, as prescribed, for the treatment of this condition. Per the Medicare compendia, The safety and efficacy of testosterone therapy have not been established in men with late-onset (age-related) hypogonadism. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Testosterone 1.62% gel.