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

You requested Zeposia (Ozanimod) Starter Pack prescribed for Crohns disease. The Part D plan denied your request because the diagnosis provided does not meet the requirements of a Food and Drug Administration 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. Your medical records show your doctor prescribed Zeposia to treat your Crohns disease. However, the Medicare approved compendium does 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 Zeposia because your diagnosis does not meet the Medicare requirement of a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Trulance (Plecanatide) 3-milligram tablet prescribed for chronic constipation. The Part D plan denied the request. We received an expedited 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. Your medical records show your doctor prescribed Trulance for your chronic constipation. A Medicare approved compendium does support the use of the requested drug for your condition. However, your doctor has tried you on lactulose with documentation of the results or if the drug would likely cause adverse events and/or would be less effective than Trulance.A physician reviewed your appeal and determined that the plan is not required to cover Trulance because the medical records do not indicate why the drug is preferred over current drugs on the plans formulary to treat your condition.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Belbuca 300 microgram buccal film prescribed twice daily for chronic back pain. The Part D Plan denied your request for a tiering exception because the records did not explain why alternative brand drugs in lower cost-share tiers wouldnt work just as well. 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. Belbuca 300 microgram buccal film is a brand drug on Tier 4 of the plans formulary. The records provided did not explain why alternative drugs of the same type to treat your condition in lower cost-share tiers wouldnt be as effective, were tried and failed, or wouldnt be appropriate. 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 Humulin R 100 units/milliliter prescribed for diabetes mellitus. 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. 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 show you prescribed Humulin R to be added to the enrollees total parenteral nutrition to treat the enrollees diabetes mellitus. The Medicare approved compendia do support the use of this biologic for this condition. However, the record shows the Humulin R is being administered with total parenteral nutrition. We requested additional medical records to determine if the total parenteral nutrition will be required for greater than three months and if it will be administered through an infusion pump. We did not receive any additional documentation. Biologics infused with durable medical equipment are eligible for coverage under Medicare Part B and may not be covered under Medicare Part D.  We determined that the plan is not required to cover Humulin R.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Cuvitru 1 gram/5 milliliter infusion prescribed for nonfamilial hypogammaglobulinemia. The Part D plan denied your request because the documentation did not support an off-formulary exception. We received an expedited 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 record shows your doctor prescribed the medication for intravenous immunoglobulin therapy at home. The plan's non-formulary coverage criteria for this medication are not met.We determined that the plan is not required to cover Cuvitru.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Synthroid 150 microgram tablets prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because there were no other brand drugs on a lower cost-sharing tier. We received an expedited 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.Synthroid is a brand drug on Tier 3 of the plans formulary. There are no brand drugs of the same type on the lower cost sharing tiers. Therefore, this drug is not eligible for a tiering exception.A physician reviewed your appeal and determined that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Lidocaine 5% patch prescribed for cancer-related polyneuropathy. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited 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 submitted documentation indicates your doctor prescribed Lidocaine patches for cancer-related polyneuropathy. This is an off-label use for the drug. The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not 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: Unfavorable

You requested Lidocaine 5% patch prescribed for edema of the legs. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited 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 submitted documentation indicates your doctor prescribed Lidocaine patches for edema of the legs. The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not 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: Unfavorable

You requested Hydroxyzine HCl 10 milligram tablets prescribed for primary insomnia. The Part D plan denied your request because the drug was not prescribed for a medically accepted indication. We received an expedited 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 submitted documentation indicates your doctor prescribed Hydroxyzine HCl for primary insomnia. The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not 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: Unfavorable

At issue is Diclofenac Sodium 1% gel prescribed for the enrollees chronic lower back pain. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. We received an expedited 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 records submitted at the reconsideration level. The documentation supports the drug was prescribed for the enrollees diagnosis of lower back pain. The Medicare approved compendia do not support the use of this drug for your condition. As the drug was not prescribed for a medically accepted indication, coverage cannot be allowed.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Aimovig 70 milligram/milliliter solution prescribed for the enrollees condition. The Part D plan denied your request for a tiering exception because there were no other biologics on a lower cost-sharing tier. We received an expedited 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.Aimovig is a biologic on Tier 4 of the plans formulary. There are no biologics of the same type on the lower cost sharing tiers. Therefore, this biologic 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 Eliquis 5 milligram tablets prescribed twice daily for the enrollees condition. The Part D plan denied your request for a tiering exception because the drug at issue was covered as a formulary exception and was not eligible for a tiering exception. We received an expedited 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 is being provided by the plan under a formulary exception. Per Medicare rules, non-formulary drugs are 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 tiering exception for Rocklatan Eye drops prescribed for primary open-angle glaucoma, bilateral. 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 asked your prescriber to send us documentation of all medications tried and failed and the reasons why the enrollee could not use the lower Brand drugs. We did not receive the information.Rocklatan Eye Drops is a Brand drug on Tier 4 of the plans formulary. There is no supporting documentation of reasons why the Brand drugs on the lower Tiers of the plans formulary could not be used. Therefore, this drug is not eligible for a tiering exception.Our Physician Reviewers opinion is that the plan is not required to grant your request for a tiering exception.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Vancomycin 25 milligrams/5 milliliters. The Part D plan denied your 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. This drug is a compounded drug. Therefore, we reviewed each ingredient individually. The ingredients of the requested drug are: Vancomycin HCL powder, Ora-sweet oral syrup, Ora-plus suspending vehicle, and water for injection.Ora-sweet oral syrup, Ora-plus suspending vehicle, and water for injection are non-prescription or over-the-counter (OTC) drugs. Medicare Part D does not cover non-prescription drugs. Therefore, the Ora-sweet oral syrup, Ora-plus suspending vehicle, and water for ingredients are not eligible for Part D coverage. Vancomycin HCL powder is a bulk Powder. Bulk powders (i.e., Active Pharmaceutical Ingredients for compounding) do not satisfy the definition of a Part D drug and are not covered by Part D. Therefore, none of the ingredients of the requested drug are Part D drugs. Compounded medications that do not contain at least one ingredient that meets the definition of a Part D drug are excluded from coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Diclofenac Sodium 1% gel. The Part D plan denied the request stating that the medication was prescribed for a non-medically accepted indication. 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 submitted documentation indicates the Diclofenac Sodium was prescribed to treat the enrollees fibromyalgia pain located in the knees and shoulder. 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 Diclofenac Sodium gel.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Pregabalin 300 milligram capsule prescribed three times daily for type 2 diabetes with diabetic polyneuropathy. The Part D plan denied your request because the quantity limit requested is higher than what the plan allows. 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. Your medical records show your doctor prescribed Pregabalin to treat your condition. The amount you were prescribed exceeds the plans number of doses that may be dispensed. There was no supporting evidence submitted to show why you require this amount. Therefore, an exception to the amount of drug requested cannot be made as the limit criteria was not met. A physician reviewed your appeal and determined that the plan is not required to cover the Pregabalin, 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 Sildenafil citrate 25 milligram tablets to treat male erectile dysfunction. The Part D plan denied the request. 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.We determined that the plan is not required to cover Sildenafil. Sexual/erectile dysfunction drugs prescribed to treat sexual/erectile dysfunction or other conditions for which the drug is not Food and Drug Administration approved, are excluded from coverage under Medicare Part D.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Cellcept 500 milligram tablets prescribed for kidney transplant. The Part D plan denied the request because the enrollees transplant was in a Medicare approved facility covered by Part A. Therefore, anti-rejection drugs are covered under Part B. We received a 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 determined that the plan is not required to cover the Cellcept. Medicare records indicate the enrollee received a kidney transplant on July 24, 2001, which was covered by Medicare Part A. Therefore, the transplant is considered a Medicare covered transplant and Cellcept is eligible under Medicare Part B. Medicare rules state that a drug covered under Part B cannot be covered under Part D. 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: Favorable

At issue is Herpes zoster vaccine. You are requesting reimbursement for the vaccine and its administration fee. We received an auto-forwarded request from the plan to reconsider the appeal.We conducted 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. No additional documentation was requested from the enrollee.The record shows you received the Herpes zoster vaccine from your physician on November 3, 2020. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. If an enrollee pays the full cost of a prescription, the enrollee may submit a request for reimbursement with proof of payment to ask the plan to pay its share of the cost. The plans formulary shows the drug is covered as a Tier 3 drug. The documentation includes a physicians billing statement and a receipt as proof of payment to the physician. We determined that the plan is required to reimburse you for their share of the cost of the Herpes zoster vaccination.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Eliquis 5 milligram oral tablet prescribed daily for pulmonary embolism. The Part D plan denied your request for a tiering exception. 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 asked your prescriber to send us information about your condition. We also asked for medical records or other documentation to show why you need the medication. Specifically, we asked for records to show why similar medications on the lower teirs would not work for you. However, we did not receive the documentation.Eliquis is a brand drug on Tier 3 of the plans formulary.  There are no brand drugs of the same type on the lower tiers of the plans formulary to treat the same 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 Zilretta 32 milligram vial prescribed for left knee osteoarthritis. 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. The record shows the physician prescribed Zilretta for the treatment of left knee osteoarthritis. However, this drug is eligible for coverage under Medicare Part B. Drugs billed by physicians and typically provided in physicians offices are covered by Medicare Part B. Therefore, this drug is not eligible for Medicare Part D coverage.We determined that the plan is not required to cover Zilretta.
Appeal type: Prescription Drug
Decision: Favorable

At issue is prescribed Repatha 140 milligram/milliter solution auto-injector. The Part D plan denied coverage because medical necessity was not established. The plan requires prior authorization before covering some prescription drugs. If prior approval is not obtained, the plan may not cover the drug. 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 records submitted at the reconsideration level. We also researched Medicare systems and reviewed the enrollment data available.We asked your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this medication. We received the documentation and included it in our review.Your medical records show your doctor prescribed Repatha to treat your mixed hyperlipidemia and familial hypercholesterolemia. The Medicare approved compendia do support the use of this drug for these conditions. In addition, the plan requires for a continuation of therapy that the enrollee has heterozygous familial hypercholesterolemia with a reduction in low-density lipoprotein cholesterol while taking Repatha before they will cover the requested drug. Medical records and laboratory reports were provided.  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 Repatha.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is a quantity limit exception for Zolpidem Tartrate 10 milligram tablets prescribed as 30 tablets per 30 days to take as needed to treat insomnia. The Part D plan did not provide a timely redetermination decision. We received an auto-forwarded reconsideration request from the plan. 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 regulations and Medicare approved compendia. The plans coverage rules indicate that Zolpidem 10 milligram tablets are covered at a limited amount of 90 tablets per 365 days. The prescriber states that the enrollee is stable on the amount prescribed. The prescriber has not provided patient specific clinical rationale to allow an exception to the quantity limits of the plan that are approved by Medicare.Our Physician Reviewers opinion is that the plan is not required to cover 30 tablets per 30 days of Zolpidem Tartrate..