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

At issue is Combivent respimat 20-100 micrograms metered dose inhaler prescribed as directed to treat the enrollees condition. The Part D plan denied your request for a tiering exception because there were no brand drugs of the same type on the lower cost sharing tiers. 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.Combivent respimat 20-100 micrograms metered dose inhaler 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. 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

You requested Budesonide 0.5 milligram/2 milliliter nebulizer solution prescribed twice daily for mild intermittent non-allergic asthma. 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 Budesonide 0.5 milligram/2 milliliter nebulizer solution to treat your mild intermittent non-allergic asthma. However, we determined that the drug is not eligible for Part D coverage. Drugs which are eligible for Part B coverage are excluded from Part D coverage by Medicare law. 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 Budesonide 0.5 milligram/2 milliliter nebulizer solution 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 Budesonide 0.5 milligram/2 milliliter nebulizer solution to the Medicare Part B carrier.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Auryxia to treat iron deficiency anemia in chronic kidney 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 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.Drugs prescribed for use as vitamins and minerals are excluded from coverage under Medicare Part D. Therefore, the requested drug is excluded from coverage.
Appeal type: Prescription Drug
Decision: Favorable

You requested TDVAX 0.5 milliliter injection prescribed for preventive care as a booster shot. We received an auto-forwarded reconsideration request from the coverage level. 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 you received a TDVAX vaccine. We asked the prescriber to send us a prescriber statement. We received the documentation and included it in our review.We determined that the plan is required to cover the TDVAX. The Medicare rules have been met.We determined that the plan is required to reimburse you for the TDVAX.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Flector 1.3% patches prescribed as directed. The Part D plan denied your request because the drug 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 documentation shows the doctor prescribed Flector patches to treat an enrollee with cervical radicular pain and inflammation, as well as chronic migraines. The physician further states the enrollee has been using Flector patches for over a year. 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 Flector patches.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Ilumya 100 milligrams per millilter subcutaneous syringe to treat plaque psoriasis. The Part D plan denied the request because the plans step therapy requirements were not met. 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 does not show that the enrollee has failed to achieve symptom control after prior therapy with or cannot use Remicade or Inflectra and Stelara. Therefore, the plans prior step therapy requirements have not been satisfied. 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 a tiering exception request for OxyContin 80 milligram tablets prescribed for treatment of migraine and atypical facial pain. 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.This drug is being provided by your plan under a formulary exception. It is not on the plans formulary but they have agreed to provide it at a cost sharing level assigned to all formulary exceptions. Per Medicare rules, non-formulary drugs are not eligible for a tiering exception.A physician reviewed your appeal and determined that the Part D plan is not required to provide a tiering exception for the requested drug.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Lantus Solostar 100 units per milliliter Pen prescribed 70 units subcutaneous once daily for diabetes mellitus. 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 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.Lantus Solostar 100 units per milliliter Pen is a non-formulary drug. 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 Remeron prescribed for bipolar II disorder. The Part D plan denied your request because the diagnosis provided does not meet the requirements 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. Your medical records show your doctor prescribed Remeron to treat your bipolar II disorder. 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 Remeron because your diagnosis does not meet the Medicare requirement of a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested coverage for Cosentyx 150 milligram per milliliter subcutaneous injections pens, 2 pens per dose (300 milligrams), to treat plaque psoriasis. The Part D plan denied the request because the prior authorization requirements were not met. 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 does not satisfy the plans coverage criteria. The prescriber has not sufficiently addressed all of the plans 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

You requested Dupixent 300 milligram/milliliter syringe prescribed daily for severe psoriasis and psoriatic arthritis. The Part D plan denied your request because the provided diagnosis is a non-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 medical records show Dupixent was prescribed to treat severe psoriasis and psoriatic arthritis. However, the Medicare approved compendia do not support the use of this drug for this condition. As such, an exceptions request based on medical necessity cannot be considered because the requested drug, as prescribed, does not meet the definition of a Medicare Part D drug. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.A physician reviewed your appeal and determined that the plan is not required to cover Dupixent.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Taltz 80 milligram injectable solution prescribed every four weeks for severe psoriasis and psoriatic arthritis. The Part D plan denied your request because the provided diagnosis is a non-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 submitted documentation shows Taltz was prescribed to treat severe psoriasis and psoriatic arthritis. The Medicare approved compendia support the use of this drug for this condition. However, there are not medical records documenting a trial of Enbrel to support the letter written by the prescriber. We contacted your office for medical records but did not receive them. Prior authorization criteria was not met. Therefore, the requested drug is not eligible for coverage under Medicare Part D for the noted condition.A physician reviewed your appeal and determined that the plan is not required to cover Taltz.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Deferasirox 360 milligram tablets prescribed as directed for thalassemia minor. The Part D plan denied your request because the provided diagnosis does 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. 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 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 Deferasirox because it was not prescribed for a medically accepted indication.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Albuterol sulfate 90 milligram solution. You requested additional reimbursement from the plan. 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 plan provided proof that the drug was covered and you were in the initial coverage phase at the time of purchase. The drug was purchased for an amount that is less than or equal to the required low-income subsidy (LIS) copayment. Therefore, our decision is the plan is not required to reimburse you for Albuterol sulfate purchased on October 1, 2020. 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 Amitriptyline hydrochloride 10 milligram tablets. You requested additional reimbursement from the plan. 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 plan provided proof that the drug was covered and you were in the initial coverage phase at the time of purchase. The drug was purchased for an amount that is less than or equal to the required low-income subsidy (LIS) copayment. Therefore, our decision is the plan is not required to reimburse you for Amitriptyline hydrochloride purchased on October 1, 2020. 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 Duloxetine hydrochloride 60 milligram capsules. You requested additional reimbursement from the plan. We received a request 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 plan provided proof that the drug was covered and you were in the initial coverage phase at the time of purchase. The drug was purchased for an amount that is less than or equal to the required low-income subsidy (LIS) copayment. Therefore, our decision is the plan is not required to reimburse you for Duloxetine hydrochloride purchased on October 16, 2020. 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 Gabapentin 300 milligram capsules. You requested additional reimbursement from the plan. We received a request 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 plan provided proof that the drug was covered and you were in the initial coverage phase at the time of purchase. The drug was purchased for an amount that is less than or equal to the required low-income subsidy (LIS) copayment. Therefore, our decision is the plan is not required to reimburse you for Gabapentin purchased on October 1, 2020. 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 Gemfibrozil 600 milligram tablets. You requested additional reimbursement from the plan. We received a request 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 plan provided proof that the drug was covered and you were in the initial coverage phase at the time of purchase. The drug was purchased for an amount that is less than or equal to the required low-income subsidy (LIS) copayment. Therefore, our decision is the plan is not required to reimburse you for Gemfibrozil purchased on October 1, 2020. 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 Lamotrigine 100 milligram tablets. You requested additional reimbursement from the plan. We received a request 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 plan provided proof that the drug was covered and you were in the initial coverage phase at the time of purchase. The drug was purchased for an amount that is less than or equal to the required low-income subsidy (LIS) copayment. Therefore, our decision is the plan is not required to reimburse you for Lamotrigine purchased on October 1, 2020. 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 Omeprazole 20 milligram capsules. You requested additional reimbursement from the plan. We received a request 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 plan provided proof that the drug was covered and you were in the initial coverage phase at the time of purchase. The drug was purchased for an amount that is less than or equal to the required low-income subsidy (LIS) copayment. Therefore, our decision is the plan is not required to reimburse you for Omeprazole purchased on October 1, 2020. 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 Warfarin 1 milligram tablets. You requested additional reimbursement from the plan. We received a request 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 plan provided proof that the drug was covered and you were in the initial coverage phase at the time of purchase. The drug was purchased for an amount that is less than or equal to the required low-income subsidy (LIS) copayment. Therefore, our decision is the plan is not required to reimburse you for Warfarin purchased on October 1, 2020. 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 Warfarin 2 milligram tablets. You requested additional reimbursement from the plan. We received a request 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 plan provided proof that the drug was covered and you were in the initial coverage phase at the time of purchase. The drug was purchased for an amount that is less than or equal to the required low-income subsidy (LIS) copayment. Therefore, our decision is the plan is not required to reimburse you for Warfarin purchased on October 5, 2020. We determined this drug was paid correctly and no further reimbursement is required by the plan.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for a tetanus, diphtheria and pertussis vaccine. We received an auto-forwarded reconsideration request from the coverage level. 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 reached out to your doctor during this review to attempt to obtain medical records regarding the vaccine, but were unsuccessful.The Part D plan is responsible for ensuring that covered Part D drugs are prescribed for medically accepted indications. The submitted documentation does not include any medical records from your physician stating why you received the vaccine. Therefore, there is insufficient information to determine if the vaccine was given for a medically accepted indication. A physician reviewed your appeal and determined that there is a lack of necessary information to reimburse you for the cost of the tetanus, diphtheria and pertussis vaccine.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Hyoscyamine Sulfate .125 milligram tablets prescribed for irritable bowel syndrome. The Part D plan denied the request because Medicare Part D does not cover less than effective Drug Efficacy Study Implementation drugs. 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 Hyoscyamine is identified as a less than effective Drug Efficacy Study Implementation drug on the Medicare website.We determined that the plan is not required to cover Hycoscyamine. Medicare Part D does not cover less than effective Drug Efficacy Study Implementation drugs. If an enrollee purchases drugs that are excluded, they must pay for them out-of-pocket. This decision does not address the medical necessity or appropriateness of the requested drug. It only establishes that payment cannot be made under the Medicare Part D benefit.