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

You requested Viberzi 75 milligram tablets prescribed for chronic diarrhea. 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 Viberzi to treat your chronic diarrhea. 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 Viberzi.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Vimpat 10 milligram/milliliter oral solution prescribed for seizure disorder. The Part D plan denied the request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.We asked your prescriber to send us information regarding the requested drug and your condition(s). We also asked for medical records. We did not receive the documentation requested.This drug may be eligible for coverage under Medicare Part A. Medicare systems confirm that the enrollee is currently in hospice care for the date of service under review. Therefore, payment could be available under Part A (hospice benefit). We determined that the plan is not required to cover Vimpat.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch prescribed daily for low 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.The documentation shows your doctor prescribed the Lidocaine patch to treat your low back pain caused by spinal stenosis in the 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 Lidocaine 5% patch.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Albuterol HFA 90 microgram prescribed for an unknown diagnosis. 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 plan reprocessed claims for the Albuterol and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Alprazolam 1 milligram tablet prescribed for an unknown diagnosis. 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 plan reprocessed claims for the Alprazolam and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ciprofloxacin hydrochloride 500 milligram prescribed for an unknown diagnosis. 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 plan reprocessed claims for the Ciprofloxacin hydrochloride and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Diclofenac sodium 1% gel prescribed for an unknown diagnosis. 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 plan reprocessed claims for the Diclofenac sodium and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Erythromycin .5% solution prescribed for an unknown diagnosis. 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 plan reprocessed claims for the Erythromycin and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Montelukast sodium 10 milligram prescribed for an unknown diagnosis. 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 plan reprocessed claims for the Montelukast sodium and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Oxycodone acetaminophen prescribed for an unknown diagnosis. 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 plan reprocessed claims for the Oxycodone acetaminophen and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pantoprazole sodium DR 40 milligram prescribed for an unknown diagnosis. 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 plan reprocessed claims for the Pantoprazole sodium and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Prednisolone acetate 1% prescribed for an unknown diagnosis. 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 plan reprocessed claims for the Prednisolone acetate and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Prednisone 5 milligram tablet prescribed for an unknown diagnosis. 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 plan reprocessed claims for the Prednisone and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sucralfate 1 gram tablet prescribed for an unknown diagnosis. 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 plan reprocessed claims for the Sucralfate and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ventolin HFA 90 micrograms prescribed for an unknown diagnosis. 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 plan reprocessed claims for the Ventolin and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Wixela 500-50 inhub prescribed for an unknown diagnosis. 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 plan reprocessed claims for the Wixela and adjusted the amount owed due to your true out of pocket accumulation. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. We reviewed the plans formulary and Evidence of Coverage. In this case, the plan paid its share of the cost for the covered drug. You are responsible for your share of the remaining copay. We have determined that the plan is correct in its calculation of your copay.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Promethazine Hydrochloride 6.25 milligrams per 5 milliliter syrup prescribed 10 milliliters every four hours for chronic abdominal pain and nausea. 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 plan denied the request due to not meeting prior authorization requirements. The documentation shows the doctor prescribed Promethazine Hydrochloride to treat the enrollees chronic abdominal pain and nausea. However, the Medicare approved compendia do not support the use of this drug for these conditions. A physician reviewed this appeal and determined that the plan is not required to cover Promethazine Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is coverage for Tretinoin 0.025% cream. The Part D plan denied the request for coverage because drugs used for cosmetic purposes are excluded from Part D 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.The documentation initially submitted to the plan indicates that Tretinoin has been prescribed to treat skin texture changes, which indicates the drug is being used for a cosmetic issue and would be excluded from Part D coverage. At reconsideration, the prescriber has requested to change the diagnosis to acne. Drugs used in the treatment of acne are not excluded from Part D coverage. However, no medical records have been submitted to validate the change in diagnosis. Therefore, there is insufficient documentation to determine if the Tretinoin is being prescribed for a purpose that is eligible for coverage under Part D. A physician reviewed the appeal and determined that the plan is not required to cover Tretinoin.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Zolinza 100 milligram capsules prescribed as directed for T-cell prolymphocytic leukemia. 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 the doctor prescribed Zolinza to treat T-cell prolymphocytic leukemia. The record shows the enrollee was previously treated with Campath, but the enrollee experienced disease progression. The prescriber indicates the enrollee is unable to receive an allogenic transplant at this time. Medical literature was submitted for review. However, the Medicare approved compendia do not support the use of this drug for the enrollees condition. A physician reviewed your appeal and determined that the plan is not required to cover Zolinza.
Appeal type: Prescription Drug
Decision: Favorable

At issue is Trikafta Therapy Pack 100-50-75 and 150 milligram tablet prescribed two tablets in morning and one tablet in the evening for cystic fibrosis. 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 records submitted at the reconsideration level.We asked the prescriber to send us information regarding the enrollees condition. We also asked for medical records or other documentation to show why this medication was needed. We received the documentation and included it in our review.The medical records show the doctor prescribed Trikafta to treat the enrollees cystic fibrosis. The plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The records show the enrollee has a D1152H mutation responsive to the drug. The prescriber and medical records state the enrollee will be transitioned from Kalydeco to Trikafta so the requested drug will not be used in combination with other medications containing Ivacaftor. 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 Trikafta.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Linzess 145 microgram capsule prescribed daily for chronic idiopathic constipation. 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.Linzess 145 microgram capsule is a brand drug on Tier 4 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers to treat your condition. 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 Cresemba 186 milligram 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.The documentation shows your doctor prescribed Cresemba for post-transplant fungal prophylaxis status post heart and lung transplant. The prescriber statement indicates the requested drug was needed to prevent possible invasive aspergillosis. The use of the requested drug as prophylaxis is an off-label use. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Cresemba.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested compounded drug Butrophanol tartrate stadol 2.5 milliliter spray 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 plan denied your request for reimbursement because some of the ingredients of the compounded drug do not meet the definition of a Part D drug. The butrorphanol tartrate and carboxymethyl sodium are powders which are on the list of drugs that are excluded from coverage under Part D. The sterile water for irrigation and sodium chloride solution are considered over-the-counter drugs and are excluded from coverage under the Part D benefit. In addition, the National Drug Codes verified with the Food and Drug Administration, are not valid. Therefore, the compounded drug is not eligible for coverage under Medicare Part D. We determined the plan is not required to provide reimbursement for the compounded drug Butrophanol tartrate stadol.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Methylphenidate Hydrochloride 5 milligram oral tablets. 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 Methylphenidate Hydrochloride for a diagnosis of depression. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Methylphenidate Hydrochloride.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Ofev 150 milligram oral capsules. 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 Ofev to treat usual interstitial pneumonitis. The Medicare approved compendia do not contain any citations to support the use of the requested drug, as prescribed, for the treatment of this condition. Therefore, the requested drug is not eligible for coverage under Medicare Part D.A physician reviewed your appeal and determined that the plan is not required to cover Ofev.