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

At issue is Rizatriptan 10 milligram oral tablet to treat an unknown diagnosis. The Part D plan denied the request stating there was insufficient documentation to determine the medical necessity and a reason for requesting a quantity of medication above the plans limit. We received an auto-forwarded reconsideration request from the plan.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 submitted a statement dated 1/11/2021 but did not provide a diagnosis.  Medical records were submitted. However, the medical records do not support a diagnosis or need for the requested drug. Without a diagnosis, it cannot be established that the requested drug is being prescribed for a medically accepted indication.  As such, the requested drug does not satisfy the definition of a Medicare Part D drug.  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 requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lyrica 75 milligram capsules prescribed as directed for peripheral neuropathy related to type II diabetes mellitus, Lyme disease, and peripheral vascular 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. We asked the prescriber to send us a supporting statement and additional medical records to support the enrollees need for this medication. However, we did not receive the documentation.The available documentation does 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 Lyrica.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Eliquis 5 milligram tablet prescribed as directed for stroke prevention. The Part D plan denied the request. We received a reconsideration 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.Eliquis 5 milligram tablet is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Favorable

You requested Boostrix 0.5 milliliter vaccination. The Part D plan denied your request because the documentation submitted did not include proof of payment receipts from the pharmacy. We received a reconsideration 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 records submitted now include proof of payment receipts from the pharmacy. The out of network requirements have now been met.A physician reviewed your appeal and determined that the plan is required to reimburse Boostrix 0.5 milliliter vaccination.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tadalafil 5 milligram tablets for benign prostate hypertrophy. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received a reconsideration request. We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We asked the prescriber to send us a prescribers statement and medical records. The prescriber has not provided patient specific clinical rationale, supported by medical records, as to why all alternatives required by the plan would likely not be as effective as the requested drug; and/or would likely cause adverse reaction(s) or other harm. Therefore, an exception to the plans formulary coverage criteria is not supported. Our physician reviewer's opinion is that formulary exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synvisc Solution 16 milligram/2 milliliter prefilled syringe prescribed to treat loss of knee cartilage. The Part D plan denied the request. We received an expedited reconsideration request. We performed and 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 device is subject to Part B and is not eligible to be covered under the Medicare Part D prescription drug benefit. We have determined that the plan is not required to cover Synvisc under the Part D prescription drug benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested First-Omeprazole 2 milligrams/milliliter suspension prescribed as directed. 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 physician prescribed First-Omeprazole suspension. First-Omeprazole suspension has not been approved by the 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.We determined that the plan is not required to cover First-Omeprazole suspension.
Appeal type: Prescription Drug
Decision: Favorable

At issue is omeprazole 2 milligram/2 milliliter solution prescribed twice daily to treat gastroesophageal reflux disease. The Part D plan denied the request. We received a reconsideration 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 medical records show you have gastroesophageal reflux disease. You are ordered not to have anything by mouth and have a jejunal feeding tube. Your physician states crushed medications are not recommended due to a high risk of clogging and a history of aspiration pneumonia. All other drugs on the plans formulary are not available in liquid form. The documentation satisfies the plans coverage criteria. A physician reviewed the appeal and determined that the requested drug is eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Renvela 800 milligram tablets prescribed to treat hyperphosphatemia. The Part D plan did not provide a timely redetermination decision. We received an auto-forwarded reconsideration request from the plan. 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 also researched Medicare regulations and Medicare approved compendia. The drug requested is not on the plans formulary. There are no medical records supporting that all alternative drugs on the plans formulary, to treat the same condition, have been tried.A physician reviewed your appeal and determined that the plan is not required to cover Renvala.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Velphoro 500 milligram tablets prescribed to treat hyperphosphatemia. The Part D plan did not provide a timely redetermination decision. We received an auto-forwarded reconsideration request from the plan. 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 also researched Medicare regulations and Medicare approved compendia. The drug requested is not on the plans formulary. There are no medical records supporting that all alternative drugs on the plans formulary, to treat the same condition, have been tried. A physician reviewed your appeal and determined that the plan is not required to cover Velphoro.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lidocaine 5 percent patch prescribed for cervical radiculopathy. The Part D plan denied your request because the medication was not prescribed for a medically accepted indication. We received a reconsideration 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 record shows you were prescribed Lidocaine 5 percent patch for cervical radiculopathy. In review of the Medicare approved compendium, cervical radiculopathy is not a medically accepted indication for Lidocaine 5 percent patch as prescribed. Therefore, it does not meet the definition of a Part D drug. The plan is not required to cover the Lidocaine 5 percent patch at issue.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a tiering exception request for Disopyramide Phosphate 100 milligram capsule to treat neurocardiogenic dysfunction/syncope and collapse. The Part D plan denied the request. We received a reconsideration 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.Disopyramide Phosphate is a generic drug on Tier 4 of the plans formulary. The prescriber has not indicated if all alternatives required by the plan have been tried and failed, or why the plans lower tiered drugs would likely not be as effective as the requested drug. Therefore, this drug is not eligible for a tiering exception.Our physician reviewer's opinion is that tiering exception criteria are not met.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Epclusa 400/100 milligram tablet to treat Chronic Hepatitis C.  The Part D plan denied the request.  We received a reconsideration 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 stated on 1/6/2021 that the requested drug was for the treatment of Chronic Hepatitis C.  On 1/11/2021, the prescriber sent a statement and answered No to the question Does the patient have genotype 1, 2, 3, 4, 5 or 6 infection?  In the request for reconsideration dated 3/11/2021, the prescriber stated that the patient has compensated liver disease and is treatment naive.  Laboratory results from date of service 3/4/2021 were provided which documented HCV RNA NAA Qualitative:  Negative result. The provided documentation does not support a diagnosis of Chronic Hepatitis C, Genotypes 1, 2, 3, 4, 5, or 6. No medical records were provided by the prescriber to support this diagnosis. 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: Favorable

You requested Scopolamine 1 milligram patch, quantity 3, provided to you while in the hospital. The Part D plan denied coverage because the National Drug Code submitted by the hospital was discontinued. We received a reconsideration request.We received a 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 National Drug Code, 48502-580-01, for Scopolamine indicated on the hospital statement was verified with the Food and Drug Administration. The number is a valid code and therefore, eligible for coverage under Medicare Part D.  We determined the plan is required to cover the Scopolamine. Please submit proof of payment for the drug to your plan for reimbursement.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ondansetron 4 milligram disintegrating tablets provided to you while in the hospital. The Part D plan denied coverage for the drug because the National Drug Code submitted by the hospital was not FDA approved. We received a reconsideration request.We received a 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 National Drug Code, 68462-157-40 indicated on the hospital statement was verified with the Food and Drug Administration. The number is invalid and therefore, not eligible for coverage under Medicare Part D. We determined the plan is not required to cover and provide reimbursement for the Ondansetron.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Panzyga 10 gram per 100 milliliter solution for nonfamilial hypogammaglobunemia. The Part D plan denied the request stating that the medication was being prescribed for a non-medically accepted indication.  At redetermination the diagnosis of acquired immunodeficiency secondary to Lamictal, nonfamilial hypogammaglobulinemia was provided. 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 the Panzyga has been prescribed for acquired hypogammaglobulinemia. 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 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 Panzyga.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Truvada 10 milligrams. The Part D plan denied the request. We received a reconsideration 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 a diagnosis. 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 a formulary exception for Nexlizet 180-10 milligram tablets. The Part D plan did not render a coverage determination. We received an auto-forwarded coverage determination 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. During this review, a request was submitted to the prescriber to provide a diagnosis, to address the formulary exception criteria, and to provide supporting medical records. The prescriber submitted the requested documentation.The records submitted by the prescribing physician indicate that the Nexlizet is being used to treat other hyperlipidemia (E78.49). 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. Since the drug is not eligible for coverage under Medicare Part D, the plan cannot be required to grant a formulary exception.A physician reviewed your appeal and determined that the plan is not required to cover the Nexlizet.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Ozempic 1 milligram per 0.75 milliliter subcutaneous injection for the treatment of type 2 diabetes with chronic kidney disease. The Part D plan denied your request because there was insufficient documentation to establish medical necessity for the medication. 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.  During this review, we requested a prescriber statement and supporting medical records from the prescribing physician. The physician submitted the requested documentation.As outlined in the Medicare approved compendia, a medically accepted indication for the use of Ozempic in the treatment of type 2 diabetes includes several criteria that must be satisfied. The prescribing physician has addressed these criteria; however, the responses do not satisfy all of the requirements for coverage of this medication. 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 reimbursement for a Shingrix vaccine. The Part D plan did not provide a timely redetermination decision. We received an auto-forwarded reconsideration request from the plan. We performed an independent and de novo review. To make our decision, we reviewed all documentation submitted. The information provided does not include a receipt of payment made by the enrollee. The requirements have not been met for reimbursement.A physician reviewed your appeal and determined that the plan is not required to reimburse the amount of the Shingrix vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sildenafil Citrate 20 milligram tablets prescribed as directed for benign prostatic hyperplasia without lower urinary tract symptoms and male erectile dysfunction, unspecified. The Part D plan denied your request because the provided diagnoses do not meet the criteria of a medically accepted indication. We received a reconsideration 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 also researched Medicare systems and reviewed the enrollment data available. Your medical records show your doctor prescribed Sildenafil Citrate one to five tablets to be taken by mouth one hour before intercourse. We determined that the plan is not required to cover Sildenafil. Drugs prescribed for the treatment of sexual or erectile dysfunction 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 Tacrolimus 1 milligram prescribed as directed following a kidney transplant. The Part D plan denied the request because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit. We received a reconsideration 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 also researched Medicare systems and reviewed the enrollment data available.Your medical records show your doctor prescribed Tacrolimus 1 milligram after a kidney transplant. The record shows that you received a kidney transplant on November 8, 2019. According to Medicare enrollment records, you were entitled to Medicare Part A coverage on June 1, 2019. Medicare law excludes coverage for any drug under the Part D program for which payment would be available under Parts A or B. Coverage is available under Medicare Part B for prescription drugs used in immunosuppressive therapy furnished to an enrollee that was covered under Medicare Part A at the time of the transplant. You were covered under Medicare Part A at the time of the transplant. 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 Tacrolimus 1 milligram because drugs that could be covered under Medicare Part B are not eligible to be covered under the Medicare Part D Prescription Drug benefit.You may wish to submit a request for Tacrolimus 1 milligram to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Briviact prescribed as directed. We received the case to perform an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. Briviact is a brand drug on Tier 5, also known as the specialty tier, of the plans formulary. If a plan maintains a specialty tier, the plan may design its exception process so that drugs placed in the specialty tier are not eligible for a tiering exception. The specialty tier is excluded from the tiering exception process. 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 Triumeq 600-50-300 milligram tablets prescribed as directed. We received the case to perform an independent and de novo review. To make our decision, we reviewed your appeal carefully. We reviewed all documentation available. Triumeq is a brand drug on Tier 5, also known as the specialty tier, of the plans formulary. If a plan maintains a specialty tier, the plan may design its exception process so that drugs placed in the specialty tier are not eligible for a tiering exception. The specialty tier is excluded from the tiering exception process. 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.