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

At issue is a request for coverage of Butalbital-Aspirin-Caffeine 50-325-40 milligram 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.The documentation indicates that Butalbital-Aspirin-Caffeine has been prescribed for the treatment of migraines. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and 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 Plavix 75 milligram tablets. 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.Plavix 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.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 Esbriet 267 milligram tablets (207 tablets per 30 days) for pulmonary fibrosis. The Part D plan denied your request for a quantity limit exception 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 indicates your doctor prescribed Esbriet to treat your pulmonary fibrosis. The drug at issue was approved as a specialty drug, which is only approved for a 30-day supply. A maximum of 2403 milligrams a month is allowed. An exception to the quantity limit criteria was not met.Therefore, the plan is not required to cover Esbriet for a quantity limit exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a prior authorization for Promethazine Hydrochloride 25 milligram tablets. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation did not include medical records to support a prescribed diagnosis. A request for information was sent to the prescriber; however, no further documentation was received. As it cannot be determined the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the requested drug.
Appeal type: Prescription Drug
Decision: Favorable

You requested Haegarda 2,000 unit vial prescribed for angioedema. 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 Haegarda to treat your angioedema. Haegarda has an orphan drug status in DrugDex, a Medicare approved compendium, and supports the use of this drug for your condition: A physician reviewed your appeal and determined that the plan is required to Haegarda.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Nitro-Bid 2% ointment. The Part D plan denied the request because the drug was being used for a non-medically accepted indication. Additionally, the drug was not included on the plans formulary and the documentation did not support a formulary 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.The documentation indicates that Nitro-Bid 2% ointment has been prescribed for the treatment of ischemic toes and pain in the fingers associated with the presence of small vessel disease and Raynauds syndrome. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the noted condition. Therefore, the drug is being prescribed for a non-medically accepted indication and is not eligible for coverage under Medicare Part D. Since the drug is not eligible for coverage under Medicare Part D, a formulary exception is not applicable to this review. 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 Diclofenac Sodium 1% gel prescribed for rheumatoid arthritis and polyneuropathy. 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 documentation shows the doctor prescribed Diclofenac Sodium 1% gel to treat the enrollees rheumatoid arthritis and polyneuropathy. However, the Medicare approved compendia do not support the use of this form of this drug for these conditions. A physician reviewed your appeal and determined that the plan is not required to cover Diclofenac Sodium 1% gel.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Xyosted 75 milligram/0.5 milliliter auto-injector prescribed weekly for hypotestosteronemia. 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. A physician reviewed your appeal and determined that the plan is not required to cover Xyosted.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Belsomra 10 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. Belsomra is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Supartz FX 25 milligram per 2.5 milliliter prefilled syringes prescribed for bilateral primary osteoarthritis of the knees. The Part D plan your request for coverage.  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.Intra-articular injections of hyaluronic acid, including Supartz FX, have been classified in the United States by the Food and Drug Administration as class III medical devices based on the presumption that the primary mechanism of action in alleviating pain is due to viscoelastic or mechanical properties of hyaluronic acid in solution rather than biological activity. As such, it does not meet the definition of a Part D drug. Therefore, the Supartz FX is not eligible for coverage under Medicare Part D. 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

You requested Xtampza 27 milligram extended-release oral capsule 90- day supply prescribed daily 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.The documentation shows your doctor prescribed Xtampza to treat your chronic pain syndrome. However, your medical records do not support why an exception to the plans quantity limit is medically necessary. Opiate prescriptions for enrollees with chronic pain are limited to a recurring 30-day supply. A longer recurring supply cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to cover the Xtampza, as the drug exceeds the number of doses that may be dispensed during a specific period of time.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Mycophenolate Sodium DR 180 milligram tablet prescribed twice daily for kidney transplant status. The Part D plan denied the request.We received the case to perform an independent and denovo 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 Mycophenolate Sodium DR following a Medicare covered kidney transplant on May 4, 2001. Therefore, the drug is eligible for coverage under Medicare Part B and excluded from Part D coverage. 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.You also requested a tiering exception for this non-formulary drug. Non-formulary drugs, when covered by Medicare Part D, are not eligible to be covered at a lower cost share. We cannot consider a tiering exception for a drug for which the Medicare Part D plan is unable to provide coverage. Therefore, the plan is not required to cover Mycophenolate Sodium DR or to grant a tiering exception for this drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Horizant extended-release 600 milligram tablets prescribed to treat post-back surgery neuropathy. 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 Horizant extended-release 600 milligram tablets to treat post-back surgery neuropathy. The Part D plan denied your request stating the formulary exception requirements were not met. 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 Horizant extended-release 600 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Fentanyl 12 microgram per hour transdermal 72-hour patches prescribed for chronic left foot pain and management of future post-operative foot pain. 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 Gralise 600 milligram tablet prescribed three tablets a day for polyneuropathy and radiculopathy, lumbar region. 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 Gralise to treat your polyneuropathy and radiculopathy, lumbar region. 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 Gralise.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a reimbursement for Budesonide-Formoterol Fumerate 160-4.5 microgram inhalant. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation does not contain medical records to support a covered diagnosis. A request for information was sent; however, no further documentation was received. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a reimbursement for Carvedilol 12.5 milligram tablets. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation does not contain medical records to support a covered diagnosis. A request for information was sent; however, no further documentation was received. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a reimbursement for Sennosides-Docusate Sodium 8.6-50 milligram tablets. 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 reimburse Sennosides-Docusate Sodium 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

You requested Dronabinol 5 milligram tablets prescribed for malignant neoplasm of both ovaries and cachexia. 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 Dronabinol to treat your malignant neoplasm of both ovaries and cachexia. 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 Dronabinol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Bisacodyl 10 milligram suppository prescribed while you were in the hospital. 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. Medicare rules state that over-the-counter drugs are excluded from coverage under Part D. The record shows you were given Bisacodyl while under observation in the hospital. This drug is considered excluded from coverage under Medicare Part D. Therefore, we determined that the plan is not required to cover the Bisacodyl or provide reimbursement. 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

You requested a reimbursement for Finasteride 5 milligram tablets. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation does not contain medical records to support a covered diagnosis. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a reimbursement for Ketoconazole 2% cream. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation does not contain medical records to support a covered diagnosis. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a reimbursement for Klor-Con 10 milliequivalent tablets. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation does not contain medical records to support a covered diagnosis. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a reimbursement for Mupirocin 2% ointment. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation does not contain medical records to support a covered diagnosis. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Polyethylene Glycol 3350 packet 17 gram prescribed while you were in the hospital. 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. Medicare rules state that over-the-counter drugs are excluded from coverage under Part D. The record shows you were given Polyethylene Glycol while under observation in the hospital. This drug is considered over-the-counter and is excluded from coverage under Medicare Part D. Therefore, we determined that the plan is not required to cover the Polyethylene Glycol or provide reimbursement. 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

You requested a reimbursement for Tamsulosin 0.4 milligram capsules. The Part D plan denied your request. We performed an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The submitted documentation does not contain medical records to support a covered diagnosis. As it cannot be determined that the drug was prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the plan is not required to reimburse the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a reimbursement for Zinc Oxide 20% ointment. 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 reimburse Zinc Oxide 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.