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

At issue is prescribed Tymlos 3120 microgram per 1.56 milliliter pen. 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. 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 did not receive the documentation requested.Your medical records show your doctor prescribed Tymlos to treat your osteoporosis. Your plan has prior authorization requirements for this drug that must be met before they will cover the requested drug. The prescriber has not sufficiently addressed the plans coverage criteria and/or the coverage criteria are not satisfied by the provided medical records.  The documentation provided does not show the enrollee has satisfied the plan's coverage criteria.A physician reviewed your appeal and determined that the plan is not required to Tymlos. The physician reviewer also determined that an exception to the plans prior authorization requirements cannot be granted at this time.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Valtrex 1 gram oral tablet. 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 your prescriber to send us information regarding 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 other medications on the plan's formulary would not work for you. However, we did not receive the documentation.You requested Valtrex 1 gram oral tablet for the provided diagnosis of Menieres disease triggered by a herpes virus infection. However, the Medicare approved compendia do not support the use of this drug for your condition. In addition, no medical records have been submitted for review to clarify this issue. Therefore, it cannot be determined if the requested drug was prescribed for a medically accepted indication. The formulary exception was not addressed because 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 Valtrex.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Armour Thyroid to treat hypothyroidism. 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.The record shows the physician prescribed Armour Thyroid. The Part D plan denied your request stating that the formulary exception requirements were not met. However, Armour Thyroid has not been approved by the United States 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Sumatriptan Succinate 100 milligram tablet prescribed 6 tablets/12 days for migraine headaches. 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 your prescriber to send us information regarding your condition. We also asked for medical records or other documentation to show why you need this amount of the medication. We did not receive the documentation requested. Your medical records show your doctor prescribed Sumatriptan Succinate to treat your migraine headaches. However, your medical records do not support why an exception to the plans quantity limit is medically necessary. A physician reviewed your appeal and determined that the plan is not required to cover the Sumatriptan Succinate 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 Synalar 0.025% topical ointment prescribed for nummular dermatitis 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 your prescriber to send us information regarding 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 other medications on the plan's formulary would not work for you. However, we did not receive medical records. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records were not received to support why other drugs on the plans formulary would not work for you. A physician reviewed your appeal and determined that the plan is not required to cover Synalar.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Tizandine 4 milligram tablet prescribed three times daily for an 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. 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 did not receive the documentation requested.. Without a diagnosis, it cannot be established that the Tizandine 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 Tizandine 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 Tizandine.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Interferon Alfa-2B 1Mu/Milliliter Ophthalmic solution for treatment of malignant neoplasm of cornea. The Part D Plan denied your 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.Medicare Part D does not cover drugs dispensed from an out-of-network pharmacy. The record shows that the enrollee obtained the Interferon-Alfa-2B 1Mu/Milliliter Ophthalmic solution from an out-of-network pharmacy. Therefore, we determined that the plan is not required to reimburse the enrollee for the drug. 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.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested reimbursement for Uro MP capsule prescribed to treat dysuria. 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.We determined that the plan is not required to cover Uro MP because it Non-Food and Drug Administration approved drug. Non-Food and Drug Administration approved drugs are excluded from Medicare Part D 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

At issue is Xifaxan 550 milligram tablet. The Part D plan denied your request for a tiering exception.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. Xifaxan tablet 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.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 request for coverage for Gabapentin 300 milligram capsules prescribed for seizure disorder.  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. The Part D plan has prior authorization requirements that have to be met before coverage of this drug is allowed. The submitted documentation does not satisfy the plans coverage criteria. During this review, a request was submitted to the prescriber to address the plans coverage requirements for the medication and to provide supporting medical records. However, the prescriber did not respond to the request. Therefore, the prior authorization criteria 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 request for coverage for Yupelri 175 microgram nebulizer solution prescribed for chronic obstructive pulmonary disease.  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. The Part D plan has prior authorization requirements that have to be met before coverage of this drug is allowed. The submitted documentation does not satisfy the plans coverage criteria. During this review, a request was submitted to the prescriber to address the plans coverage requirements for the medication and to provide supporting medical records. However, the prescriber did not respond to the request. Therefore, the prior authorization criteria 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 Tremfya Injector 100 milligram/milliliter prescribed for plaque psoriasis. 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. Your prescriber indicates they prescribed Tremfya Injector 100 milligram/milliliter to treat plaque psoriasis. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. The information we have from the prescriber does not state why all other drugs on the plans formulary would not work for you. We requested additional information from your prescriber. We did not receive any additional documentation. A physician reviewed your appeal and determined that the plan is not required to cover Tremfya.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Gralise extended-release 600 milligram tablets prescribed to treat fibromyalgia and spondylosis. 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 Gralise extended-release 600 milligram tablets to treat fibromyalgia and spondylosis. The Part D plan denied your request stating that the provided diagnoses were non-medically accepted indications. The diagnosis of fibromyalgia is listed as non-Food and Drug Administration use for Gralise. DRUGDEX, a Medicare approve compendium states, Anticonvulsant agents, including gabapentin, can be used for fibromyalgia, based on clinical evidence of reduced pain; but, the meaningful effect may be small. However, Gralise is not on your plans formulary. In order to grant an exception for a drug not on the plans formulary, alternative formulary drugs must have been tried, failed, or deemed contraindicated. In this case, the medical records do not support why other drugs on the plans formulary would not work for you.A physician reviewed your appeal and determined that the plan is not required to cover Gralise extended-release 600 milligram tablets.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hyophen 81.6-0.12 milligram tablet prescribed for the treatment of urethral syndrome. The Part D plan denied your request.We received the case to perform an independent and de novo review. To make our decision, we read your case file carefully. We reviewed all documentation submitted. This includes the case file from the plan, and any information submitted at the reconsideration level. We determined that the plan is not required to cover the Hyophen. According to Medicare rules, Hyophen has not been approved by the Food and Drug Administration. Therefore, the drug is excluded from coverage under Medicare Part D. This decision does not concern the medical necessity or appropriateness of the requested drug. It only establishes if payment can be made under the Medicare Part D benefit.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Pregabalin 75 milligram oral capsule prescribed daily. The Part D plan denied your request for a tiering exception.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. Pregabalin is a generic drug on Tier 3 of the plans formulary. There are no generic 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

At issue is Leflunomide 20 milligram oral tablet prescribed daily. The Part D plan denied your request for a tiering exception.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. Leflunomide is a brand drug on Tier 3 of the plans formulary. The medical records do not support that all drugs available on lower tiers to treat your condition have been tried or deemed contraindicated. 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 Corlanor 5 milligram oral tablet prescribed daily for sinus tachycardia. 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 Corlanor to treat your sinus tachycardia. 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 Corlanor.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Epidiolex solution 100 milligram/milliliter prescribed for generalized convulsive seizures/epilepsy. 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 Epidiolex to treat your generalized convulsive seizures/epilepsy. However, the Medicare approved compendia do not support the use of this drug for your condition due to not being related to Lennox-Gastaut syndrome, Dravet syndrome, or tuberous sclerosis syndrome. A physician reviewed your appeal and determined that the plan is not required to cover Epidiolex.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Hetlioz 20 milligram capsule prescribed for your non-24 hour sleep-wake disorder. 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 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 did not receive the documentation requested.The documentation supports the drug was prescribed for non-24 hour sleep-wake disorder in a sighted enrollee. However, medical records to establish a medically accepted indication have not been provided. There are specific clinical determinants of this condition detailed in the International Classification of Sleep Disorders, Third Edition (ICSD-3), in order to establish this diagnosis. The provided records do not establish this diagnosis.A physician reviewed your appeal and determined that the requested drug is not eligible for Part D coverage.
Appeal type: Prescription Drug
Decision: Unfavorable

You requested First-Omeprazole 2 milligram/milliliter suspension. The Part D plan denied your 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 drug at issue is not Food and Drug Administration approved. 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: Favorable

You requested Boostrix 0.5 milliliter injection prescribed for shingles vaccination. We received the case to perform an independent and de novo review of this request for coverage. We reviewed all documentation submitted for review, including the case file from the plan, and any information submitted at the reconsideration level. The record shows you received the Boostrix vaccine at your physicians office. Medicare rules allow a Part D plan to apply coinsurance and copayments to covered drugs. The plans Evidence of Coverage states that payment for vaccines including administration fee is required up front from the enrollee when provided at an out of network pharmacy or provider's office. 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 2 drug. The documentation submitted includes a statement from the physicians office that the Boostrix vaccine and administration fee was paid in full by the enrollee. Therefore, we determined that the plan is required to reimburse you for their share of the cost for the Boostrix vaccine and administration fee.
Appeal type: Prescription Drug
Decision: Unfavorable

At issue is Testosterone gel 20.25 milligram/actuation (1.62%). At initial determination and redetermination a diagnosis of endocrine disorder was provided. 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.At reconsideration level a diagnosis of personal history of other endocrine, nutritional and metabolic disease was given, with indication of Testosterone gel 50 milligram/5 gram (1%) being requested. We asked your prescriber to send us information regarding your condition. We also asked for medical records and other documentation. We did not receive the documentation requested.In this case, we reviewed Testosterone gel 20.25 milligram/actuation (1.62%). Your medical records reveal a diagnosis of hypogonadism. However, the Medicare approved compendia do not support the use of this drug for your condition due to not being related to testicular failure from conditions such as; cryptorchidism, bilateral torsions, orchitis, vanishing testis syndrome, orchiectomy, Klinefelter syndrome, chemotherapy, or toxic damage from alcohol or heavy metals, or from idiopathic gonadotropin or luteinizing hormone-releasing hormone deficiency, or pituitary-hypothalamic injury from tumors, trauma, or radiation.A physician reviewed your appeal and determined that the plan is not required to cover Testosterone gel 20.25 milligram/actuation (1.62%).
Appeal type: Prescription Drug
Decision: Unfavorable

You requested Shingrix 50 microgram/.5 milliliter suspension prescribed for vaccination. 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 submitted documentation that shows you were still in the deductible stage of the Part D benefit when you were administered the vaccination at your pharmacy. Your plans Evidence of Coverage states that you are responsible for the full cost of covered drugs until the deductible amount is satisfied. We determined the amount you paid was applied to your deductible and no reimbursement is required by the plan.