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

You requested Zolpidem tartrate 10 milligram tablets prescribed for unknown diagnosis. The Part D plan denied your 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 plan submitted documentation that shows you were in the initial coverage stage of the Part D benefit when this drug was purchased. 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 record shows the plan paid its share of the cost for the Zolpidem tartrate and the remaining amount was your copay for a tier 2 drug filled at a preferred pharmacy. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Anoro ellipta prescribed as directed for an unknown diagnosis. The Part D plan denied the 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 records submitted at the reconsideration level. The prescriber was asked to state the diagnosis since the diagnosis was not contained within the appeal. The prescriber was asked questions to clarify the medical history and to provide documentation to support the noted diagnosis. The prescriber was also asked questions to address the plans formulary alternatives. A response from the prescriber was not received. Therefore, based upon the current record, it could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Budesonide 0.5 milligram/2 milliliter ampul-neb prescribed for unknown diagnosis. The Part D plan denied your requestWe 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 Budesonide was purchased from a network pharmacy to be administered through a nebulizer. Medicare Part B covers 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 reimburse for the Budesonide. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol Sulfate HFA 90 microgram aerosol inhaler prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows you purchased Albuterol sulfate from a preferred pharmacy for an amount that is less than or equal to the required copayment 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. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested a tiering exception for Advair Diskus 250-50 microgram inhalation powder prescribed for chronic obstructive pulmonary disease. The Part D plan forwarded the request to us for review. 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. Advair Diskus is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type to treat the noted condition on the lower cost sharing tiers. If there are no brand drugs of the same type on a lower tier, the drug is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to cover the Advair Diskus at a lower cost tier level.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Olmesartan medoxomil 40 milligram tablets prescribed for unknown diagnosis. The Part D plan was unable to review your case timely and auto-forwarded 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 purchased Olmesartan medoxomil from a preferred pharmacy for an amount that is less than or equal to the required copayment 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. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Metoprolol succinate 25 milligram extended release 24 hour tablets prescribed for unknown diagnosis. The Part D plan was unable to review your case timely and auto-forwarded 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 purchased Metoprolol succinate from a preferred pharmacy for an amount that is less than or equal to the required copayment 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. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pregabalin 75 milligram capsules prescribed for unknown diagnosis. The Part D plan was unable to review your case timely and auto-forwarded 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 purchased Pregabalin from a preferred pharmacy for an amount that is less than or equal to the required copayment 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. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Fluoxetine hydrochloride 40 milligram capsules prescribed for unknown diagnosis. The Part D plan was unable to review your case timely and auto-forwarded 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 purchased Fluoxetine hydrochloride from a preferred pharmacy for an amount that is less than or equal to the required copayment 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. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tamsulosin hydrochloride 0.4 milligram capsules prescribed for unknown diagnosis. The Part D plan was unable to review your case timely and auto-forwarded 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 purchased Tamsulosin hydrochloride from a preferred pharmacy for an amount that is less than or equal to the required copayment 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. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac sodium 3% gel prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows you purchased Diclofenac sodium from a preferred pharmacy for an amount that is less than or equal to the required copayment 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. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Revlimid 20 milligram capsules prescribed for unknown diagnosis. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level.The record shows you purchased Revlimid 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/coinsurance 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 coinsurance. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Oxycodone hydrochloride 15 milligram tablets prescribed for unknown diagnosis. The Part D plan was unable to review your case timely and auto-forwarded 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 purchased Oxycodone hydrochloride from a preferred pharmacy for an amount that is less than or equal to the required copayment 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. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: At-Risk Determination
Decision: Unfavorable

You requested Ipratropium-albuterol 0.5-3 milligram/3 ampul-neb prescribed for unknown diagnosis. The Part D plan denied your requestWe 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 Ipratropium-albuterol was purchased from a network pharmacy to be administered through a nebulizer. Medicare Part B covers 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 reimburse for the Ipratropium-albuterol. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Azelaic acid 15 % gel prescribed as directed for acne vulgaris. The Part D plan denied the request.We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The prescriber was asked to send in medical records to support the diagnosis listed. We did not receive a response from the prescriber. Therefore, based upon the current record, it could not be determined whether the requested drug was being prescribed for a medically accepted indication. Therefore, the requested drug is not eligible for coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol sulfate 2.5 milligram/3 milliliter vial  prescribed for use with a nebulizer for bronchitis. The Part D plan denied your requestWe 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 Albuterol sulfate is being administered through a nebulizer for use in the home setting. Medicare Part B covers 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 reimburse for the Albuterol sulfate. Please submit your request to Medicare Part B.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Oxycodone 15 milligram tablets prescribed 180 tablets per 30 days for chronic pain syndrome. 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 for information regarding your condition. We also asked for medical records or other documentation to show why the enrollee needs this amount of the medication. We did not receive the documentation requested.The records show you prescribed Oxycodone 15 milligram tablets to treat the enrollees chronic pain syndrome. An exception to the quantity limit criteria was not met. Therefore, the plan is not required to cover the requested quantity of Oxycodone 15 milligram 180 tablets per 30 days.A physician reviewed your appeal and determined that the plan is not required to cover the Oxycodone 15 milligram tablets, 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 Benzoyl Peroxide Erythromycin gel 5/3% to treat acne. This case was auto-forwarded.We performed an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available.The record shows Benzoyl Peroxide Erythromycin gel was prescribed; however, Benzoyl Peroxide Erythromycin gel is a non-formulary drug and is not eligible for a tiering exception. A physician reviewed your appeal and determined that the plan is not required to grant a tiering exception for the Benzoyl Peroxide Erythromycin gel.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lamotrigine 100 milligram oral dissolvable tablet prescribed twice daily for focal epilepsy with impairment of consciousness. 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 prescriber was asked to send in medical records to support a diagnosis. We received a response and have included it in our review.The records do not show why the enrollee cannot take other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover the Lamotrigine 100 milligram oral dissolvable tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lamotrigine 25 milligram oral dissolvable tablet prescribed twice daily for focal epilepsy with impairment of consciousness. 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 prescriber was asked to send in medical records to support a diagnosis. We received a response and have included it in our review.The records do not show why the enrollee cannot take other drugs on the plans formulary for their condition. A physician reviewed your appeal and determined that the plan is not required to cover the Lamotrigine 25 milligram oral dissolvable tablet.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for a tiering exception for Dayvigo 5 milligram tablets prescribed for 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. Dayvigo is not included in the plans formulary. The Part D plan does not grant tiering exceptions to non-formulary drugs. Therefore, the Dayvigo is not eligible for coverage at a lower-cost tier. 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

At issue is Lidocaine 5% patch to treat left shoulder pain. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Citic Acid Monohydrate/Potassium Citrate 334 milligrams-1100 milligrams/5 milliliters prescribed to treat urinary stones. 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 not listed as a Food and Drug Administration approved drug. Therefore, it is excluded from Medicare Part D drug benefits.A physician reviewed your appeal and determined that the plan is not required to cover Citric Acid Monohydrate/Potassium Citrate.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a request for coverage of Gabapentin 400 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 Gabapentin has been prescribed for chronic pain and pain during ejaculation. However, the Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the noted conditions. Therefore, the drug is being prescribed for non-medically accepted indications and 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 Gabapentin.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Alprazolam ER 1 milligram tablets. The Part D plan denied the request. We performed an independent and de novo review. We reviewed all documentation submitted. This includes the case file from the plan and any information submitted at the reconsideration level.The prescriber was asked to send in medical records to support the diagnosis listed. We did not receive a response from the prescriber. Therefore, based upon the current record, it could not be determined whether the requested drug was being prescribed for a medically accepted indication. 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 the Alprazolam ER.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested ZTLIDO 1.8 percent patches prescribed as directed for complex regional pain syndrome of right lower extremity, hypersensitivity, and allodynia. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available. The use of the requested drug to treat the provided diagnoses 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 these conditions. Therefore, the drug cannot be considered for payment under the Part D benefit.A physician reviewed your appeal and determined that the plan is not required to cover the ZTLIDO 1.8 percent patches.